Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to request, refuse, and/or discontinue treatment, to
participate in or refuse to participate in experimental research, and to formulate an
advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the resident’s
physician’s order sheet (POS) included the resident’s code status (whether or not the
resident wants to be resuscitated during respiratory or [MEDICAL CONDITION]) for two
sampled residents (Residents #4 and #610); and to ensure the code status was completed
timely and added to the POS for two sampled residents (Residents #102 and #610) out of 23
sampled residents. The facility census was 113 residents.
1. Record review of Resident #4’s entry tracking form showed he/she moved into the
facility on [DATE].
Record review of the resident’s census sheet showed he/she was placed on hospice
(end-of-life care) on 3/22/19.
Record review on 4/16/19 8:47 A.M. showed the resident’s Admission Minimum Data Set (MDS-a
federally mandated assessment tool completed by facility staff for care planning) dated
3/27/19 was incomplete.
Record review of the resident’s care plan dated 3/27/19 showed the resident was a full
code (all life-saving measures are taken in order to treat a patient after/during a
respiratory or [MEDICAL CONDITION]).
Record review of the resident’s (MONTH) 2019 and (MONTH) 2019 POS showed the resident’s
code status was left blank.
Record review on 4/12/19 at 10:42 A.M. showed the outside of the resident’s chart did not
have a full code or a Do Not Resuscitate (DNR – an order from a doctor that resuscitation
should not be attempted if a person suffers cardiac or respiratory arrest) sticker.
During an interview on 4/15/19 at 8:00 A.M., the Social Worker said:
-He/she keeps track of the residents’ code status information in an excel file.
-Residents’ code status information should be on the care plans and should be on the POS.
-His/her excel file shows the resident is a full code.
-A form is kept in the chart that shows the residents’ code status information and he/she
collaborates with nursing staff to update the forms as necessary.
During an interview on 4/15/19 at 7:58 A.M., Licensed Practical Nurse (LPN) E said:
-Residents who are a full code have a green sticker on the outside of the chart.
-The resident would be a DNR as there was not a full code sticker on the outside of the
chart.
During an interview on 4/16/19 at 8:31 A.M., the resident said he/she wanted to be full
code and no one talked to him/her about his/her code status.
During an interview on 4/19/19 at 10:56 AM, the Director of Nursing (DON) said:
-The nurses should look at the residents’ POS to determine their code status.
-The admitting nurse should put the resident’s code status on the POS.
2. Record review of Resident #102’s Face Sheet showed he/she was admitted to the facility
on [DATE] with a [DIAGNOSES REDACTED].)
Record review of the resident’s POS dated 3/12/19 showed there was no documentation of the
resident’s code status.
Record review of the resident’s Social Services Notes dated 3/14/19 showed:
-Advanced directives summary.
–The resident had advanced directives and would give these to the social worker and
–The resident wanted to be a DNR.
Record review of the resident’s Care Plan dated 3/16/19 showed the resident was a full

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
code.
Record review of the resident’s admission MDS dated [DATE] showed he/she was cognitively
intact.
Record review of the resident’s POS dated 3/19/19 showed:
-Code status:
–Full code yes or no and
-The resident’s code status was not updated on the POS.
During an interview on 4/15/19 at 8:47 A.M. the resident said:
-He/she had talked with the Social Services Director (SSD) and the SSD had offered him/her
advanced directives and code status.
-He/she had asked to be a DNR and
-He/she did not want to be resuscitated.
During an interview on 4/16/19 at 8:53 A.M. the SSD said:
-The resident had his/her Advanced Directives completed at the hospital.
-The resident had provided these to the facility and
-He/she had completed the DNR paperwork with the resident on 4/11/19 and was waiting for
the physician to sign it.
During an interview on 4/18/19 at 11:04 A.M., LPN A said:
-The nurses were responsible for obtaining the resident’s code status and
-The nurse was responsible for ensuring this was updated on the resident’s POS.
During an interview on 4/19/19 at 10:57 A.M., the DON and Corporate Nurse B said:
-Upon admit, he/she expected the nurse to obtain the resident’s code status.
-The resident should be a full code until the DNR was signed by the physician and
-The nurse should mark the code status on the resident’s POS.
3. Record review of Resident #610’s Face sheet showed he/she had been admitted on [DATE]
with the following Diagnoses: [REDACTED].
-Vertebral fracture (bones in the spine crumble).
-Diabetes (a group of diseases that result in too much sugar in the blood).
-The code status was left blank.
-The advance directive was left blank.
-The resident had a guardian.
Record review of the resident’s POS dated March- (MONTH) 2019 showed:
-The code status was not marked.
-The advance directive status was not marked and
-The resident’s physician had signed it.
Record review of the resident’s Nurse’s Progress Notes dated 4/9/19 showed:
-The resident is comatose (a period of prolonged unconsciousness brought on by illness or
injury).
-The resident was not oriented to person, place or time.
-The resident was non verbal and
-The resident was in a vegetative state.
Record review of the resident’s Baseline Care Plan dated 4/9/19 showed the code status was
marked as a full code with a question mark after it (full code?).
Observation on 4/11/19 at 2:00 P.M. showed:
-The resident had vomited.
-The nursing staff was working on him/her and
-The resident was sent to the hospital.
During an interview on 4/15/19 at 8:00 A.M., the Social Worker said:
-He/she keeps track of the residents’ code status information in an excel (computer) file.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
-The resident’s code status information should be on the care plans.
-The resident’s code status should be on the POS.
-His/her excel file showed the resident was a full code.
-A form is kept in the chart that shows the residents’ code status information and
-The Social Worker collaborates with the nursing staff to update the forms as necessary.
During an interview on 04/18/19 at 10:01 A.M., the DON said:
-The resident went to hospital on [DATE] and
-The resident was still there.
During an interview on 4/18/19 at 10:15 A.M., LPN A said:
-When a resident goes to the hospital the Face sheet, medication list, history and
physical, laboratory results, and code status should be sent with the resident.
-The family or guardian should be called and
-The Physician should be called.
During an interview on 4/19/19 at 10:56 A.M. the DON said:
-The nurses should look at the residents’ POS to determine their code status.
-The admitting nurse should put the resident’s code status on the POS.
-On admission a resident is considered a full code until DNR (Code status) is established.
-The code status should be on the POS for an emergency.
-The admitting nurse is responsible for doing it.
-The Social Worker should put a sticker on the outside of the resident’s chart (indicating
code status) and
-The DON was the Admitting Nurse for this resident.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
furniture in a resident room was in good repair, and the personal refrigerator and items
in it were at a safe temperature for one sampled resident (Resident #70), out of 23
sampled residents. The facility census was 113 residents.
1. Record review of Resident #70’s face sheet showed the resident was admitted to the
facility 2/15/19 and his/her [DIAGNOSES REDACTED].
-[MEDICAL CONDITION] (decline in mental ability caused by an impaired supply of blood to
the brain).
-Type II Diabetes Mellitus (a long-term metabolic disorder characterized by high blood
sugar, insulin resistance, and relative lack of insulin).
-Subarachnoid Hemorrhage (a life-threatening type of stroke caused by bleeding into the
space surrounding the brain).
Record review of the resident’s Admission Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by facility staff for care planning) dated
2/21/19 showed the resident was:
-Cognitively impaired.
-Needed limited physical assistance with bed mobility and transfers.
-Needed extensive physical assistance with dressing and toileting.
-Was independent with eating.
Record review of the resident’s care plan initiated 2/25/19 and revised 3/4/19, showed the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
resident had a cognitive deficit, and staff interventions included providing a safe
environment.
Observation of the resident’s room on 4/11/19 at 1:16 P.M. showed a family member who was
visiting with the resident opened the door of the resident’s night stand. When the family
member opened the door of the resident’s night stand, the door fell and was hanging to the
side.
Observation on 4/11/19 at 1:18 P.M., showed:
-The resident had a small personal refrigerator located in his/her room.
-There was no thermometer in the refrigerator to ensure a safe temperature was maintained.

-There was a container of left over soup in the refrigerator.
-The resident had chicken that was brought in by the family for his/her lunch that he/she
did not finish and wanted it placed in his/her refrigerator for later.
During an interview on 4/11/19 at 1:20 P.M., the resident’s family member said:
-He/she reported the broken night stand to the facility staff, but did not remember the
exact day.
-He/she did remember reporting the broken furniture to staff prior to the resident going
to the hospital. (*Note: The resident was hospitalized [DATE].)
-The soup in the resident’s refrigerator had been there for about a week.
-He/she would not want the resident to eat it because it was too old.
-He/she tried to check the resident’s refrigerator weekly when he/she came to visit.
Observation on 4/11/19 at 1:36 P.M. showed:
-The Social Worker came and met with the family member.
-Registered Nurse (RN) B joined the Social Worker and the family member in a discussion
about the concerns that the family member had. During the discussion RN B said a new night
stand was brought in.
–The night stand was sitting on the other side of the room, not on the resident’s side of
the room.
–Neither the resident nor the resident’s family member knew the night stand was for the
resident.
–The resident’s personal belongings were not placed in the new night stand.
–The broken night stand was not removed.
During an interview on 4/19/19 at 9:14 A.M., Certified Nurse Assistant (CNA) H said:
-The nurse checks the residents’ refrigerators.
-No one told him/her the resident had a new night stand sitting on the other side of the
room.
-He/She did not know the resident had a new night stand until he/she saw the old one moved
out to the hall and the new one was in place.
-He/She thought whoever moved the resident’s old night stand out into the hall must have
put the new one into place and put the resident’s personal items into his/her new night
stand.
During an interview on 4/19/19 at 10:56 A.M., the Director of Nursing said:
-There should be thermometers in all refrigerators.
-Maintenance should be checking the refrigerators.
-The night stand should have been replaced when the resident was admitted into the
facility.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Based on interview and record review, the facility failed to ensure the Criminal
Background Checks (CBC) and the Employee Disqualification List (EDL) checks were completed
prior to hire for one newly hired employee (Employee B) out of eight sampled newly hired
employees. The facility census was 113 residents.
Record review of the facility’s policy titled Background Checks updated 6/2018, showed:
-This facility will conduct employment background screening reference checks on
individuals making application for employment with this facility.
-The Human Resources (HR) Director or designee will conduct background checks and
reference checks on persons considered for employment with this facility prior to hire.
1. Record review of Employee #B’s personnel information showed:
-He/she was hired on 3/4/19.
-The EDL check was not completed until 4/13/19.
-The CBC was not completed prior to hire.
During an interview on 4/18/19 at 9:21 A.M., the HR Director said:
-The CBC should have been completed prior to hire.
-He/she ran one after he/she started.
-He/she started working in the building two days prior to the survey start date, 4/9/19.
During an interview on 4/19/19 at 10:56 A.M., the Director of Nursing (DON) said:
-He/She would have expected the CBC and EDL check to have been completed by the previous
HR Director.
-CBC and EDL checks should always be completed prior to hire.

F 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a
condition of admission; and must tell residents what care they do not provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a resident was
provided with the facility’s Admission Agreement and had opportunities to ask questions
related to the Admission Agreement for two sampled residents (Resident’s #110 and #309)
out of 23 sampled residents. The facility census was 113 residents.
Record review of the facility’s admission agreement dated 11/20/18 showed:
-The admission agreement contained:
–Financial arrangements.
–Authorizations and assignments from the resident to the facility.
–Temporary absence including the bed hold policy.
–Discharge, transfer, and room changes.
–Personal property.
–Facility security.
–Smoking policy.
–Governing laws and
–General provisions.
1. Record review of Resident #110’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Nurses’ Notes, dated 3/6/19 showed he/she was admitted to
the facility for weakness to receive skilled rehabilitation therapy services (services

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
that help a person regain cognitive (mental) and/or physical abilities that have been lost
or impaired as a result of disease, lack of use or injury).
Record review of the resident’s medical record showed no documentation that the resident
was provided an Admission Agreement to include the resident’s rights, the facility’s
special characteristics and service limitations, facility policies, requirement for
payment, and conditions for transfer and discharge.
During an interview on 4/18/19 at 11:18 A.M. the Acting Admissions Director said:
-The Admissions Director at the time of the resident’s admission should have provided the
resident with the Admissions Agreement.
-He/she heard the resident had refused to sign the Admission Agreement and
-Admission Agreements should be given to the Business Office to be filed.
During an interview on 4/18/19 at 11:30 A.M. the Business Office Director said:
-The Admissions Director is supposed to give him/her the Admissions Agreement packet after
it is presented to the resident and signed.
-If the resident refuses to sign the agreement the Admissions Director writes Refused on
the packet and gives the agreement to him/her to be placed in the resident’s file in the
Business Office.
-He/she should receive an Admissions Agreement packet for each resident admitted whether
or not the resident signs it; and
-He/she didn’t think the facility got with the resident at all to sign the agreement or
he/she would have received the agreement packet with either the resident’s signature or
the word Refused written on it.
During an interview on 4/19/19 at 10:58 A.M. the Director of Nursing (DON) said:
-Upon admission the resident should be given an Admission Agreement which contains
information pertinent to the resident such as the resident’s rights, conditions for
treatment, and facility policies relevant to the resident such as smoking, bed holds,
visitation, and passes out of facility.
-The resident should sign he/she received the information on the day of admission.
-If the resident refuses to sign the Admissions Agreement a note should be written that
the information was provided, but the resident refused to sign. The Admissions Director
should get a witness that the resident refused to sign.
-The Admission Agreement packet should be given to the Business Office Director for
him/her to file and
-An Admission Agreement was not available for the resident.
2. Record review of Resident #309’s Face Sheet showed he/she was admitted to the facility
on [DATE] for skilled services and had the following Diagnoses: [REDACTED]. Subcutaneous
fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but
does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling).
-Non-pressure chronic ulcer of the back with necrosis (dead tissue) of the bone; and
-[MEDICAL CONDITION] (loss of movement of both legs and generally the lower trunk).
Record review of the resident’s Admission Note dated 4/4/19 showed:
-The resident was admitted for physical and occupational therapy services; and
-The resident’s goal was to complete therapy and return to the community.
During an interview on 4/15/19 at 8:13 A.M., the resident said:
-The facility never signed admission paperwork with him/her.
-He/she would like to have his/her admission paperwork; and
-He/she only signed something that authorized payments to the facility.
During an interview on 4/15/19 at 11:07 A.M. the Admissions Coordinator said:
-He/she was from another facility and had been at this facility for about two and a half
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
weeks.
-He/she was responsible for completing admission paperwork for the residents.
-He/she completed the admission paperwork within 24-48 hours after admission with the
resident or the resident’s responsible party.
-He/she had not been here at the time of this resident’s admission; and
-He/she would check to see if the resident had signed the admission agreement.
During an interview on 4/15/19 at 11:07 A.M. the Admissions Coordinator said:
-He/she had looked for the resident’s admission agreement and
-The admission agreement had not been signed by the resident.
During an interview on 4/19/19 at 10:57 A.M., the DON and Corporate Nurse B said:
-The resident should have signed the admission agreement the day of admit and
-The Admissions Coordinator was responsible for ensuring the admission agreement was
signed by the resident or the resident’s responsible party.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide in writing a
transfer/discharge notice for six sampled residents (Residents #33, #54, #70, #83, #92,
and #40); to notify the Ombudsman (a resident advocate who provides support and assistance
with problems and/or complaints regarding the facility) of the resident’s
transfer/discharge for six sampled residents (Residents #33, #54, #70, #83, #92, and #40)
and to assist the resident with submission of his/her appeal of his/her 30-day discharge
for one sampled resident (Resident #54) out of 23 sampled residents. The facility census
was 113 residents.
Record review of the facility’s transfer/discharge process policy dated (MONTH) (YEAR)
showed:
-The resident and/or their representative will receive written notice of the facility’s
intent for transfer/discharge and their appeal rights prior to the time of
transfer/discharge.
1. Record review of the Resident #54’s assessments and tracking forms showed:
-The resident entered the facility on 11/7/18.
-The resident’s admission Minimum Data Set (MDS-a federally mandated assessment tool
completed by facility staff for care planning) dated 11/13/18 showed the staff assessed
the resident as cognitively intact.
-The resident was discharged with return anticipated on 12/19/18 and
-The resident re-entered the facility on 12/22/18.
Record review of the resident’s medical record showed no documentation of the resident’s
notification of transfer/discharge on 12/19/18 or a 30-day discharge notice dated 3/26/19.
Record review of the resident’s notice of discharge (which was not placed in the
resident’s medical record) dated 3/26/19 showed:
-The resident would be discharged [DATE].
-He/she would be discharged to another facility owned by the facility’s current company or
another facility of his/her choosing.
-The letter showed that the resident could appeal to the Missouri Department of Health and
Senior Services or the State Office of Long Term Care Ombudsman but it did not include any

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
contact information for the two agencies.
During an interview on 4/11/19 at 10:35 A.M., the resident said he/she was given a 30-day
discharge notice for non-payment effective 4/25/19 and he/she wants to appeal it.
During an interview on 4/15/19 6:52 A.M., the Social Worker said:
-He/she started working at the facility at the end of (MONTH) 2019.
-The resident has talked to him/her about his/her 30 day discharge notice and
-He/she thinks the resident’s discharge is due to non-payment.
During an interview on 4/16/19 at 12:01 P.M., the Director of Nursing (DON) said:
-The resident was given a 30 day notice for what he/she believes was non-payment.
-They offered him/her the appeal process.
-Administrator A (who no longer worked at the facility as of 4/18/19) offered to assist
him/her with his/her appeal and
-As of last week, the resident’s appeal had not been completed.
During an interview on 4/18/19 at 10:49 A.M., the Social Worker said:
-They have a new process in which the Social Worker will do discharge to the community
notices and nursing staff will do hospital transfer/discharge notices.
-The resident is being discharged due to non-payment.
-He/She follows up with residents who have been given a discharge notice for non-payment.
-He/She tries to come up with a discharge plan for those residents who have been given a
30-day discharge notice for non-payment.
-There should be documentation regarding the resident’s discharge and the discharge plan
in the medical record.
-The resident told him/her sometime last week he/she wanted to appeal and he/she needed
help with sending the appeal.
-The resident did not bring the appeal form to him/her.
-He/she did not seek the resident out to assist him/her sending the appeal form and
-The resident has gone by his/her office a few times saying they needed to send the form.
During an interview on 4/19/19 at 10:56 AM, the DON said:
-Social Services should assist residents with their appeal.
-Social Services should try to assist with discharge planning and
-The Social Worker should document what’s been done regarding the resident’s discharge.
2. Record review of Resident #92’s assessments and tracking forms showed:
-The resident entered the facility on 3/9/19.
-The resident’s admission MDS dated [DATE] showed the staff assessed the resident as
cognitively intact.
-The resident was discharged with return anticipated on 4/1/19 and
-The resident re-entered the facility on 4/8/19.
Record review of the resident’s medical record showed no documentation of the resident’s
notification of transfer/discharge on 4/1/19.
During an interview on 4/18/19 at 10:49 A.M. the Regional Social Worker said:
-The bed hold were supposed to be done by the business office manager.
-They identified on 3/28/19 that they were not doing notice of transfers and discharges
and
-The new process is that the Social Worker is responsible for sending discharge to
community notices and the ombudsman notification and nursing is responsible for doing
discharge to hospital notices.
During an interview on 4/19/19 at 10:56 AM, the DON said:
-The nurse is responsible for sending the transfer discharge notice to the resident and/or
their responsible party when a resident goes out to the hospital.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
-The Social Worker is responsible for providing the residents and/or their responsible
party with a transfer/discharge notice when being discharged (facility-initiated) to the
community and
-Administrator A (who no longer worked at the facility) was responsible for notifying the
ombudsman of the residents who have been transferred/discharged .
3. Record review of an email dated 4/8/19 from the Ombudsman showed the Ombudsman
requested from the facility the list of residents transferred and discharged (MONTH) 2019
through (MONTH) 2019.
4. Record review of Resident #70’s face sheet showed he/she was admitted to the facility
on [DATE] and his/her [DIAGNOSES REDACTED].
Record review of the resident’s Admission MDS dated [DATE], showed he/she was cognitively
impaired.
Record review the resident’s nurse’s note dated 3/22/19, showed he/she was transferred
from the facility to the hospital on [DATE].
Review of the resident’s medical record showed there was no letter notifying the
resident’s representative of a transfer and the reason for the transfer.
Record review of the resident’s nurse’s note dated 3/26/19, showed he/she returned to the
facility on [DATE].
Review of the resident’s medical record showed there was no record of the facility
notifying the Ombudsman of the resident’s transfer and the reason for the transfer.
5. Record review of Resident #83’s face sheet showed he/she was admitted to the facility
on [DATE]. His/Her current [DIAGNOSES REDACTED].
Record review of the resident’s Significant Change MDS dated [DATE], showed he/she was
cognitively impaired.
Record review the resident’s nurse’s note dated 3/10/19 showed he/she was transferred from
the facility to the hospital on [DATE].
Review of the resident’s medical record showed there was no letter notifying the
resident’s representative of a transfer and the reason for the transfer.
Record review of the resident’s nurse’s note dated 3/15/19, showed he/she returned to the
facility on [DATE].
Review of the resident’s medical record showed there was no record of the facility
notifying the Ombudsman of the resident’s transfer and the reason for the transfer.
During an interview on 4/16/19 at 2:40 P.M. the Social Worker said:
-He/she did not have documentation to show the residents or resident representatives
received a discharge notification when the resident was discharged to the hospital and
-There was no documentation to show discharge documentation was sent to the Ombudsman.
6. Record review of Resident #40’s Admission Record showed he/she was admitted on [DATE]
and readmitted on [DATE].
Record review of the resident’s MDS dated [DATE] showed his/her cognition was intact.
Record review of the resident’s Nurses Note dated 1/13/19 at 1:02 A.M. showed he/she was
transferred to the hospital.
Review of the resident’s medical record showed there was no documentation of a letter
notifying the resident and/or representative, or notification to the Ombudsman of the
transfer and the reason for the transfer.
Record review of the resident’s Nurses Note dated 1/29/19 at 10:17 P.M., showed the
resident returned to the facility.
7. Record review of Resident #33’s Face sheet showed he/she was admitted on [DATE] and
readmitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (a condition in which the blood does not have enough red blood
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
cells).
-[MEDICAL CONDITION] (excess body fat that increases the risk of health problems).
-[MEDICAL CONDITION] (sudden loss of heart function, breathing, and consciousness).
-Pressure ulcer stage 3 (a wound that extends through the second layer of the skin).
-Fistula (an abnormal connection between organs).
-[MEDICAL CONDITION] (a slower than normal heart rate).
-Dysphasia (a difficulty swallowing) and
-[MEDICAL CONDITION] (a surgical procedure that creates an opening from the neck into the
windpipe to provide an airway and to remove secretions from the lungs).
Record review of the resident’s admission MDS dated [DATE] showed:
-The resident had no problem communicating with staff.
-The resident had the ability to understand others.
-Needed the assistance of two staff for all activities of daily living and
-The resident was able to make his/her own decisions.
Record review of the resident’s Nurse’s Progress Notes dated 4/9/19 did not show any
transfer papers were sent with the resident when he/she went to the hospital on [DATE].
During an interview on 4/16/19 at 12:30 P.M. the resident said:
-He/she had just got out of the hospital.
-He/she had went into the hospital on [DATE] and
-He/she was released on 4/12/19.
During an interview on 4/16/19 at 2:10 P.M., Licensed Practical Nurse (LPN) A said:
-The nurse was responsible for sending the transfer sheet, face sheet, medication list,
any laboratory work, code status, and physician’s orders [REDACTED].>-He/she could not
find any transfer/discharge paperwork.
During an interview on 4/18/19 at 10:00 A.M., the DON said:
-The resident went to the hospital on [DATE] with return anticipated.
-The resident was readmitted to the facility on [DATE].
-The transfer/discharge sheet was not sent with the resident to the hospital.
-The resident’s face sheet was not sent with the resident to the hospital.
-The list of the resident’s medications was not sent with the resident to the hospital.
-The physician’s orders [REDACTED].
-He/she did not know why this happened and
-All the above were supposed to go to the hospital when a resident goes to the hospital.
During an interview on 4/19/19 at 11:04 A.M. with the DON said the Social Worker and the
Nurse were responsible for a resident transfer.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to provide the facility’s
bed-hold information and agreement prior to being transferred/discharged to the hospital
for five sampled residents (Residents #33, #92, #70, #83, and #40) out of 23 sampled
residents. The facility census was 113 residents.
Record review of the facility’s bed-holds and returns policy dated (MONTH) 2019 showed the
resident would receive bed hold information and agreement prior to being transferred.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
1. Record review of Resident #92’s entry tracking form dated 3/9/19 showed he/she entered
the facility on 3/9/19.
Record review of the resident’s telephone order dated 4/1/19 showed a physician’s orders
[REDACTED].
Record review of the resident’s medical record showed no documentation of the bed hold
information and agreement being provided to the resident 4/1/19-4/8/19.
Record review of the resident’s admission note dated 4/8/19 showed the resident returned
to the facility.
During an interview on 4/18/19 at 10:49 A.M.:
-The Social Worker said the bed hold notice was supposed to be provided by the business
office manager.
-The Regional Social Worker said:
–The bed hold notices were supposed to be done by the business office manager.
–They identified on 3/28/19 that they were not doing notices of transfers and discharges
so he/she thinks the bed holds were not being sent either and
–The new process is that the business office manager is responsible for bed hold policy
notification.
During an interview on 4/18/19 at 11:06 A.M., the business office manager said he/she does
not send the bed hold policy for any resident discharges.
During an interview on 4/19/19 at 10:56 AM, the Director of Nursing (DON) said the bed
hold policy is provided to the resident and/or their responsible party by the Social
Worker.
2. Record review of Resident #70’s face sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 3/18/19, showed
he/she was cognitively impaired.
Record review the resident’s nurse’s note dated 3/22/19, showed he/she was transferred
from the facility to the hospital on [DATE].
Record review of the resident’s medical record showed no documentation of the facility’s
bed hold policy being given to the resident’s representative when the resident was
transferred to the hospital.
3. Record review of Resident #83’s face sheet showed he/she was admitted to the facility
on [DATE]. His/her current [DIAGNOSES REDACTED].
Record review of the resident’s Significant Change MDS dated [DATE], showed the resident
was cognitively impaired.
Record review the resident’s nurse’s note dated 3/10/19 showed he/she was transferred from
the facility to the hospital on [DATE].
Record review of the resident’s medical record showed no documentation of the facility’s
bed hold policy being given to the resident’s representative when the resident was
transferred to the hospital.
During an interview on 4/16/19 at 2:40 P.M. the Social Worker said neither the residents
nor the residents’ representatives were given a copy of the bed hold policy when the
residents discharged to the hospital.
During an interview on 4/18/19 at 8:41 A.M., the Regional Social Worker said when someone
goes to hospital nursing staff should handle making sure the resident and/or the
resident’s responsible party gets a copy of the bed-hold policy.
During an interview on 4/19/19 at 10:56 A.M., the DON said the Social Worker should be
giving the bed-hold policy to the resident or the resident’s representative when the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
resident is discharged to the hospital.
4. Record review of Resident #40’s Admission Record showed he/she was admitted on [DATE]
and readmitted on [DATE].
Record review of the resident’s MDS dated [DATE] showed his/her cognition was intact.
Record review of the resident’s Nurses Note dated 1/13/19 at 1:02 A.M. showed the resident
was transferred to the hospital.
Record review of the resident’s medical record showed no documentation of the facility’s
bed hold policy being given to the resident and/or representative when the resident was
transferred to the hospital.
Record review of the resident’s Nurses Note dated 1/29/19 at 10:17 P.M., showed that the
resident returned to the facility.
5. Record review of Resident #33’s Face sheet showed he/she was admitted on [DATE] and
readmitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (a condition in which the blood does not have enough red blood
cells).
-[MEDICAL CONDITION] (excess body fat that increases the risk of health problems).
-[MEDICAL CONDITION] (sudden loss of heart function, breathing, and consciousness).
-Pressure ulcer stage 3 (a wound that extends through the second layer of the skin).
-Fistula (an abnormal connection between organs).
-[MEDICAL CONDITION] (a slower than normal heart rate);
-Dysphasia (a difficulty swallowing); and
-[MEDICAL CONDITION] (a surgical procedure that creates an opening from the neck into the
windpipe to provide an airway and to remove secretions from the lungs).
Record review of the resident’s admission MDS dated [DATE] showed:
-The resident had no problem communicating with staff.
-The resident had the ability to understand others.
-Needs the assistance of two staff for all activities of daily living; and
-The resident is able to make his/her own decisions.
During an interview on 4/16/19 at 12:30 P.M. the resident said:
He/she had just got out of the hospital.
-He/she had went into the hospital on [DATE] and
-He/she was released on 4/12/19.
Record review of the resident’s Nurse’s Progress Notes dated 4/9/19 did not show the
bedhold papers were sent with the resident when he/she went to the hospital on [DATE].
During an interview on 4/16/19 at 2:10 P.M. with LPN A said he/she did not know who sends
out the bedhold policy.
During an interview on 4/18/19 at 10:00 A.M., the DON said:
-The resident was at the hospital from 4/9/19 to 4/12/19.
-The bedhold policy was not sent with the resident to the hospital.
-The resident’s face sheet was not sent with the resident to the hospital.
-The list of the resident’s medications was not sent with the resident to the hospital.
-The physician’s orders [REDACTED].
-He/she did not know why this happened; and
-All the above were supposed to go to the hospital when a resident goes to the hospital.
During an interview on 4/9/19 at 11:04 A.M., the DON said the Social Worker was
responsible for sending the bed hold policy.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assess the resident completely in a timely manner when first admitted, and then
periodically, at least every 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to complete a
comprehensive assessment within 14 calendar days after the resident’s admission for two
sampled residents (Residents #4 and #358) out of 23 sampled residents. The facility census
was 113 residents.
1. Record review of Resident #4’s assessments and tracking forms showed:
-The resident entered the facility on 12/10/18.
-An admission Minimum Data Set (MDS-a federally mandated assessment tool completed by
facility staff for care planning) was completed on 12/16/18.
-The resident was discharged with return anticipated on 1/7/19.
-The resident re-entered the facility on 1/7/19.
-The resident was discharged with return anticipated on 1/20/19.
-The resident re-entered the facility on 1/28/19.
-The resident was discharged with return anticipated on 1/31/19 and
-The resident re-entered the facility on 3/15/19 (after being gone for more than 30 days).
Observation on 4/11/19 2:19 P.M. showed the resident was asleep in bed on a low air loss
mattress (a specialty mattress with a series of air sacs in which the pressure can be
adjusted to provide pressure redistribution and provides a continuous flow of air across
the surface of the mattress which prevents moisture build-up on the skin), was receiving
oxygen, had a nebulizer (a device used to administer medication to people in the form of a
mist inhaled into the lungs) and a [MEDICAL CONDITION] (Continuous Positive Airway
Pressure-a machine that provides pressure during exhalation to decrease work of breathing
and assist with obstructive tissues) on his/her bedside dresser.
During an interview on 4/12/19 at 10:47 A.M., the resident said he/she was in hospital for
pneumonia (lung inflammation caused by infection).
Record review on 4/15/19 at 9:04 A.M. and on 4/16/19 at 8:47 A.M. showed the resident’s
3/27/19 admission MDS for his/her 3/15/19 admission was not completed.
During an interview on 4/18/19 11:26 at A.M., the MDS Coordinator said:
-The resident was gone for over 30 days, so he/she would need a new admission MDS.
-The resident went on hospice during the first week of his/her return to the facility so
they needed to do a significant change MDS.
-The resident’s admission MDS should have been done already and
-He/she just hasn’t done the resident’s MDS.
2. Record review of Resident #358’s face sheet showed he/she was admitted to the facility
on [DATE]. The resident’s [DIAGNOSES REDACTED].>-Hypertension (HTN – high blood
pressure).
-[MEDICAL CONDITION] (CAD – the buildup of cholesterol and fatty deposits (called plaques)
on the inner walls of the arteries).
-[MEDICAL CONDITION] (increased levels of lipids or fat proteins in their blood).
-[MEDICAL CONDITION] with [MEDICAL CONDITION] (acute or chronic cognitive deterioration
due to diffuse or focal cerebral infarction that is most often related to [MEDICAL
CONDITION] disease) and
-Psychiatric Disorder (a behavioral or mental pattern that causes significant distress or
impairment of personal functioning).
Record review on 4/18/19 of the resident’s Electronic Health Record showed:
-The resident was admitted to the facility on [DATE] and
-The resident’s Admission MDS was completed 4/17/19 (more than 14 days after his/her

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
admission).
Record review on 4/18/19, of the resident’s Comprehensive Admission MDS, dated [DATE],
showed:
-Section C, related to the resident’s cognitive patterns was blank.
-Section D, related to the resident’s mood was blank.
-Section E, related to the resident’s behavior showed the resident displayed physical
behavior (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually),
which occurred 1-3 days during the assessment period.
-Section N, related to the types of medications the resident received, showed the resident
received the following types of medications daily during the assessment period:
–Antipsychotic (used to treat psychotic ( severe mental disorder in which thought and
emotions are so impaired that contact is lost with external reality) disorders).
–Antianxiety (used to treat anxiety ( feeling of worry, nervousness, or unease, typically
about an imminent event or something with an uncertain outcome) and
–Antidepressant (used to treat depression (feelings of severe despondency and dejection).
During an interview on 4/18/19 at 11:38 A.M., the MDS Coordinator said he/she was working
on getting the MDS records up to date. He/she was behind on some of them.
During an interview on 4/19/19 at 10:56 A.M., the Director of Nursing (DON) said he/she
would expect the resident’s MDS to be completed in accordance with the RAI (Resident
Assessment Instrument) manual.

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure resident’s with a
mental disorder and individuals with intellectual disability had a DA-124 level I screen
(used to evaluate for the presence of psychiatric conditions to determine if a
preadmission screening/resident review (PASARR) level II screen is required) as required,
for one sampled resident (Resident #102) out of 23 sampled residents. The facility census
was 113 residents.
Record review of the Missouri Department of Health and Senior Services (DHSS) guide
titled, PASARR Desk Reference, dated 3/3/08, showed:
-The PASARR is a federally mandated screening process for any person for whom placement in
a Medicaid Title (XIX) certified bed is being sought. This is a Level I screening
(completion of the DA124C form). (In this facility, all beds are Medicaid certified).
-A Level II assessment is completed on those persons identified at Level I who are known
or suspected to have a serious mental illness (such as [MEDICAL CONDITION], dementia,
[MEDICAL CONDITION], etc., MR or related MR condition to determine the need for
specialized service (completion of the DA124A/B form). The facility responsible for
completing the DA124A/B and/or DA124C forms is also responsible for submitting completed
form(s) to DHSS, Division of Regulation and Licensure, Section for Long Term Care
Regulation, Central Office Medical Review Unit (COMRU).
-PASARR screening is required: To assure appropriate placement of persons known or
suspected of having a mental impairment,
-To assure that the individual needs of mentally impaired persons can be and are being met
in the appropriate placement environment,
-To be compliant with the OBRA/PASARR federal requirements, see 42 CFR 483.Subpart C, and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
-To assure Title XIX funds are expended appropriately and in accordance with Legislative
intent.
-To comply with PASARR requirements, the facility must maintain a legible copy on file of
the DA124C and Level II Screening Report for each resident until the resident is
transferred. If a legible copy is not maintained, the facility must complete and submit a
new set of DA124A/B and C forms to COMRU,
-If a resident is discharged to a new nursing home, the receiving facility is responsible
for assuring the DA124C and Level II screening results are included in the transfer
packet, and
-Should the DA124C not be included in the packet, admission should not be completed. The
DA124C and Level II screening results should be requested from the prior facility by the
receiving facility.
-The Guide To Intensive Psychiatric Treatment Guidelines, (instructions that are included
with the DA124 forms), dated 9/07, showed the following: Definition – inpatient
psychiatric hospitalization and/or any intensive mental health service provided by mental
health professionals that is required to stabilize or maintain a person experiencing major
mental disorder,
-Services may be rendered within their current residence, and
-The services are not merely medication changes, weekly counseling sessions or routine
outpatient visits.
Record review of the facility’s Screen/PASRR revised 5/2018 showed:
-The admissions department would obtain a Level 1 Screen (DA-124) for all admissions prior
to being accepted to and arriving at the facility;
-The admissions department would ensure if a Level 1 screening required a Level II PASRR
evaluation was required a Level II PASRR evaluation was completed and obtained for those
individuals prior to admission to the facility;
-Any admission whose Level 1 screen indicated a Level II PASRR was required must have the
Level II PASRR evaluation completed prior to admission to the facility;
-If a resident in the facility was newly diagnosed with [REDACTED].
1. Record review of Resident #102’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Major [MEDICAL CONDITION].
-Personal history of self-harm.
-Alcohol dependence, in remission; and
-Cocaine abuse.
Record review of the resident’s admission note dated 3/12/19 showed he/she:
-Was admitted to the facility for a [DIAGNOSES REDACTED].
-Was alert and oriented, had a history of [REDACTED].
Record review of the resident’s DHSS Level One Nursing Facility PASRR Screening for Mental
Illness/Mental [MEDICAL CONDITION] or Related Condition dated 3/12/19 showed:
-The resident had a [DIAGNOSES REDACTED].
-The staff marked the resident had no signs of a major mental disorder; and
-A Level II was not indicated as being necessary for the resident.
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by facility staff for care planning) dated
3/18/19 showed he/she:
-Was cognitively intact.
-Did not have behaviors; and
-Did not have a PASRR completed.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
Record review of the resident’s physician progress notes [REDACTED].
-The resident had racing thoughts.
-The resident was currently admitted to the long-term care unit.
-He/she suffers from multiple medical problems to include recent history of [MEDICAL
CONDITION] exacerbation as well as positive influenza.
-He/she carried an extensive psychiatric history to include having been treated in the
past for [MEDICAL CONDITION] disorder, polysubstance abuse to include cocaine and
[MEDICATION NAME], as well as anxiety and depression.
-While at a local hospital he/she was seen by psychiatry, and started on [MEDICATION NAME]
and [MEDICATION NAME] 100 milligrams (mg) at bedtime.
-While here at the facility his/her [MEDICATION NAME] has been increased to 40 mg daily.
-The resident was started on [MEDICATION NAME] at 0.5 mg twice a day for increased
anxiety.
-Assessment: (of diagnoses);
–[MEDICAL CONDITION] disorder-manic phase.
–Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety); and
–Depression.
Record review of the residents Nursing Progress Note dated 4/1/19 showed:
-The resident went to his/her appointment at a psychiatrist office.
-The psychiatrists’ office called and stated there were some concerns about his/her
stating he/she wanted to harm himself/herself and they felt it best if he/she be seen in
the emergency room prior to returning to the facility; and
-Nursing agreed that would fine.
Record review of the resident’s Nursing Progress Note date 4/8/19 showed:
-The resident was readmitted to the facility from the hospital; and
-The resident was readmitted for long-term care.
Record review of the resident’s hospital medical record dated 4/8/19 showed:
-The resident was discharged to the nursing home in stable condition.
-The resident was seen for medical conditions and for psychiatric conditions.
-Aftercare recommendations were outpatient treatment.
-The resident had the following Diagnoses: [REDACTED].
-Anxiety disorder and
-[MEDICAL CONDITION] ([MEDICAL CONDITION]-a mental health condition that’s triggered by a
terrifying event – either experiencing it or witnessing it. Symptoms may include
flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the
event).
Record review of the resident’s Medical Record on 4/17/19 showed no Level II was in the
medical record.
During an interview on 4/16/19 at 8:53 A.M., the Social Services Director (SSD) said:
-He/she did not complete the PASRRs for the resident.
-The Business Office Manager was responsible for completing the PASRRs for the residents.
-He/she viewed the resident’s Level I.
-Only the Level I PASRR was completed for the resident on 3/12/19.
-The Level I should have the [DIAGNOSES REDACTED].
-The Level I should have triggered a Level II.
During an interview on 4/16/19 at 9:26 A.M., the Business Office Manager (BOM) said:
-He/she was responsible for completing the residents’ PASRR.
-He/she was not aware the resident had a [DIAGNOSES REDACTED].
-He/she was not aware of the resident’s psychiatric history.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
-He/she did not trigger a Level II when the resident was admitted .
-He/she was not aware the resident had a psychiatric stay at the hospital; and
-He/she did not complete a Level I and trigger a Level II after the resident’s psychiatric
stay.
During an interview on 4/19/19 at 10:57 A.M., the Director of Nursing (DON) and Corporate
Nurse B said:
-The Business Office Manager (BOM) was responsible for completing the resident’s PASRR;
and
-The Level I should have triggered a level II due to the resident’s [DIAGNOSES REDACTED].

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop a
baseline care plan within 48 hours for one sampled resident (Resident #92) and to provide
a summary of the baseline care plan for four sampled residents (Residents #92, #70, #40,
and #42) out of 23 sampled residents. The facility census was 113 residents.
Record review of the facility’s baseline care plan policy dated (MONTH) (YEAR) showed:
-A baseline care plan would be developed within 48 hours of the resident’s admission.
-The resident and their representative will be provided a written summary of the baseline
care plan by the completion of the comprehensive care plan.
1. Record review of Resident #92’s entry tracking form dated 3/9/19 showed he/she entered
the facility on 3/9/19.
Record review of the resident’s medical record showed no baseline care plan for the
resident’s admission on 3/9/19.
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 3/12/19 showed he/she
was cognitively intact.
Record review of the resident’s comprehensive care plan dated 3/13/19 showed he/she:
-Was a fall risk.
-Was at risk for declining in his/her abilities to care for himself/herself.
-Was receiving hospice (end of life care) services.
-[MEDICAL CONDITION] and
-Was at risk for pain.
Record review of the resident’s nurse’s note dated 4/1/19 showed he/she had a change in
condition related to a fall.
Record review of the resident’s telephone orders showed a physician’s orders [REDACTED].
Record review of the resident’s entry tracking form showed the resident returned to the
facility on [DATE].
Record review of the resident’s baseline care plan dated 4/8/19 showed no documentation
that a summary of the resident’s baseline care plan was provided to the resident or
his/her responsible party.
Observation on 4/15/19 at 6:45 A.M. showed the resident was asleep in bed.
Observation on 4/16/19 at 8:39 A.M. showed the resident was in his/her room with a
visitor.
During an interview on 4/18/19 8:30 A.M., Regional Nurse B said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
-The signature of who received the baseline care plan (the resident or their responsible
party) should be on the baseline care plan.
-The admitting nurse or unit manager is responsible for the developing the baseline care
plan and providing it to resident and/or their responsible party and obtaining their
signature on it.
During an interview on 4/18/19 at 10:41 A.M., Licensed Practical Nurse (LPN) F said:
-The admitting nurse does the baseline care plan.
-The admitting nurse does not give the baseline care plan to the resident or their
responsible party and
-The MDS coordinator follows up on the care plans.
During an interview on 4/18/19 at 10:49 A.M., the Social Worker said he/she does not give
the baseline care plan to the resident or their responsible party.
During an interview on 4/18/19 at 11:26 A.M., the MDS Coordinator said:
-He/She does not do anything with the baseline care plan and
-He/She doesn’t know who is supposed to give a summary of the baseline care plan to the
resident or their responsible party.
During an interview on 4/19/19 at 10:56 A.M., the Director of Nursing (DON) said:
-The admitting nurse completes the baseline care plan upon admission.
-The admitting nurse prints a copy of the baseline care plan and gives it to the resident
and/or their responsible party and
-If the admitting nurse doesn’t do the baseline care plan, then the nurse manager or
whoever does the baseline care plan should print it off, take it to the resident, go over
it, have the resident or their responsible party sign it and the facility keeps a copy.
2. Record review of Resident #70’s face sheet showed he/she was admitted to the facility
2/15/19. His/her [DIAGNOSES REDACTED].
-[MEDICAL CONDITION] (decline in mental ability caused by an impaired supply of blood to
the brain).
-Diabetes Mellitus (a long-term metabolic disorder characterized by high blood sugar,
insulin resistance, and relative lack of insulin) and
-Subarachnoid Hemorrhage (a life-threatening type of stroke caused by bleeding into the
space surrounding the brain).
Record review of the resident’s Progress Note dated 2/15/2019 showed he/she was admitted
to the facility on [DATE], and a baseline care plan was established which included the
following information along with other information related to the resident’s status and
care:
-The resident could communicate easily with staff.
-His/her visual and hearing status was adequate.
-His/Her functional status included some self-care performance.
-The resident was cognitively impaired and
-The resident did not smoke.
**(Note: Daily observation of the resident during the survey showed the resident going out
to smoke during Smoking Break times.)
Record review of the resident’s baseline care plan dated 4/8/19 showed no documentation
that a summary of the resident’s baseline care plan was provided to the resident or
his/her responsible party.
Observation of the resident on 4/15/19 at 9:59 A.M., showed the resident was outside in
the smoking area, supervised by staff. The resident was able to put his/her ashes from
his/her cigarette into the ash tray.
Observation on 4/15/19 at 10:12 A.M., showed the resident coming in from smoking,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
propelling himself/herself down the hall to his/her room.
During an interview on 4/19/19 at 9:34 A.M., LPN E said:
-The admitting nurse only puts the baseline care plan in the computer.
-The only documentation the family or responsible party signs is the admission paper work
and
-We do not give the family a copy of the baseline care plan.
3. Record review of Resident #40’s Admission Record showed he/she admitted on [DATE].
Record review of the resident’s baseline care plan dated 1/29/19 showed:
-No documentation of the resident and/or family/representative being provided a copy of
the baseline care plan or a summary of it and
-A blank signature line.
Record review of the resident’s Nurses Notes dated from 1/29/19 through 2/8/19 showed no
documentation of the resident and/or family/representative being provided a copy of the
baseline care plan or a summary of it.
Record review of the resident’s comprehensive care plan dated 2/3/19 showed he/she:
-Had alteration in skin integrity (refers to skin health, may mean the skin is damaged,
vulnerable to injury or unable to heal normally).
-Had bowel incontinence.
-Had a wound infection.
-Had an alteration in respiratory system due to a [MEDICAL CONDITION] (surgical opening
into the wind pipe into which a tube is inserted to allow passage of air and removal of
secretions)
-Had an indwelling catheter (a tube passed into the bladder to drain urine into a drainage
bag) due to stage 4 pressure ulcer (localized injury to the skin and/or underlying tissue
usually over a bony prominence, as a result of pressure, or pressure in combination with
shear and/or friction) to the coccyx (small bone at base of the spine).
-Was a fall risk.
-Was at risk for pressure ulcer development due to history of pressure ulcers.
-Required total assistance with activities of daily living.
-Required tube feeding per a Percutaneous Endoscopic Gastrostomy (PEG – a tube inserted
through the abdominal wall into the stomach to deliver nutrition) tube for his/her
nutrition.
-Was at risk for altered hydration and nutrition status related to noting by mouth status,
and on tube feeding and
-Used [MEDICAL CONDITION] medications (any drug capable of affecting the mind, emotions,
and behavior including stimulants, antidepressants, antipsychotics, mood stabilizers, and
antianxiety agents).
4. Record review of Resident #42’s Admission Record showed he/she admitted on [DATE].
Record review of the resident’s baseline care plan dated 1/29/19 showed:
-No documentation of the resident and/or family/representative being provided a copy of
the baseline care plan and
-A blank signature line.
Record review of the resident’s Nurses Notes dated from 1/29/19 through 2/8/19 showed no
documentation of the resident and/or family/representative being provided a copy of the
baseline care plan or a summary of it.
Record review of the resident’s Admission Note dated 1/29/2019 at 7:45 P.M., showed
Baseline Care Plan Summary:
-The resident’s preference for being notified to updates of plan of care were:
–As changes occur and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
–During normal care plan meetings.
Record review of the resident’s comprehensive care plan dated 2/6/19 showed he/she:
-Had the potential for weight loss.
-Had impaired skin integrity due to a left above knee amputation.
-Was a smoker.
-Was at risk for pain.
-Received antidepressant medications related to a [DIAGNOSES REDACTED].
-Had an infection in his/her left above knee amputation surgical site and
-Was at risk for pressure ulcer development.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to accurately
document the administration of as needed pain medication for two sampled residents
(Resident #67 and #71), and to follow a physician’s orders [REDACTED].#71), out of 23
sampled residents. The facility census was 113 residents.
Record review of the facility’s medication administration general guidelines policy dated
(MONTH) (YEAR) showed:
-The individual who administers the medication records the administration on the
resident’s Medication Administration Record (MAR) directly after the medication is given
and
-When as needed medications are administered, the following documentation is provided:
date and time of administration, dose, complaints or symptoms for which the medication was
given, results achieved from giving the medication and the time results were noted,
signature or initials of the person recording administration and signature or initials of
the person recording effects, if different from the person administering the medication.
1. Record review of Resident #67’s annual Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 2/20/19 showed
he/she:
-Received scheduled pain medication, as needed pain medication and non-medication
interventions for pain and
-Said he/she was almost constantly in pain and the worst the pain had been in the lookback
period was a nine out of ten with ten being the worst possible pain.
Record review of the resident’s pain care plan dated 2/20/19 showed he/she was at risk for
pain and received scheduled pain medications.
Record review of the resident’s Controlled Medication Utilization Records for [MEDICATION
NAME] 7.5/325 milligrams (mg) (an opioid pain medication) showed there was no Controlled
Medication Utilization Record for the resident’s [MEDICATION NAME] 7.5/325 mg for 3/1/19
through 3/4/19 at 6:00 A.M.
Record review of the resident’s Controlled Medication Utilization Records for [MEDICATION
NAME] 7.5/325 mg for 3/4/19 at 6:00 A.M. through 3/31/19 at 5:45 P.M. showed two tablets
were administered 36 times.
Record review of the resident’s (MONTH) 2019 MAR showed:
-A physician’s orders [REDACTED].
-[MEDICATION NAME] 7.5/325 mg, two tablets was documented on the front of the MAR as

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
administered 19 times (17 times less than documented on the Controlled Record).
-The administration was documented on the back of the MAR twice.
–The time and initials were not included two out of two opportunities on the back of the
MAR and
–There were no results documented two out of two opportunities on the back of the MAR.
Record review of the resident’s Controlled Medication Utilization Records for [MEDICATION
NAME] 7.5/325 mg for 4/1/19-4/4/19 showed documentation that one tablet (each tablet was
indicated as double tablets) was administered nine times. Some of the documentation of the
dose given indicated one and others indicated two.
Record review of the resident’s (MONTH) 2019 MAR for 4/1/19-4/5/19 showed no documentation
of the administration of [MEDICATION NAME] 7.5/325 mg.
Record review of the resident’s Controlled Medication Utilization Records for [MEDICATION
NAME] 7.5/325 mg showed there was no Controlled Medication Utilization Record for the
resident’s [MEDICATION NAME] 7.5/325 for 4/4/19 after 12:00 P.M. through 4/11/19 at 9:30
P.M.
Record review of the resident’s (MONTH) 2019 physician’s orders [REDACTED].
Record review of the resident’s (MONTH) 2019 MAR for 4/6/19-4/12/19 showed:
-A physician’s orders [REDACTED].
-[MEDICATION NAME] 7.5/325 mg was documented on the front of the MAR as administered three
times.
-The administration was documented on the back of the MAR four times and
-The order dated 4/6/19 for [MEDICATION NAME] 7.5/325 mg, two tablets every eight hours as
needed for pain was discontinued on 4/12/19.
Record review of the resident’s telephone order dated 4/12/19 showed:
-A physician’s orders [REDACTED].
-A new order for [MEDICATION NAME] 7.5/325 mg, one tablet every eight hours as needed for
pain.
Record review of the resident’s Controlled Medication Utilization Record for [MEDICATION
NAME] 7.5/325 mg for 4/11/19-4/17/19 showed:
-It was administered 12 times from 4/11/19-4/17/19.
-The quantity of tablets received indicated 30 with 15 written in next to the 30 and
circled.
-The administration was documented as:
–4/11/19 at 9:30 P.M., one tablet was given with 14 remaining.
–4/12/19 at 6:30 A.M., one tablet was given with 13 remaining.
–4/12/19 at 1:00 P.M., two tablets were given with 12 remaining.
–4/12/19 at 10:15 P.M., two tablets were given with 11 remaining.
–4/13/19 at 6:00 P.M., one tablet was given with 10.5 remaining.
–4/14/19 at 5:30 A.M., one tablet was given with 10 remaining.
–4/14/19 at 9:30 P.M., one tablet was given with 9.5 remaining.
–4/15/19 at 9:00 A.M., one tablet was given with 9 remaining.
–4/15/19 at 9:30 P.M., one tablet was given with 8.5 remaining.
–4/16/19 at 12:30 P.M., one tablet was given with 8 remaining.
–4/17/19 at 12:30 P.M., one tablet was given with 7.5 remaining and
–4/17/19 at 8:30 P.M., one tablet was given with 7 remaining.
Record review of the resident’s (MONTH) 2019 MAR for 4/11/19-4/17/19 showed:
-A physician’s orders [REDACTED].
-[MEDICATION NAME] 7.5/325 was documented on the front of the MAR as administered five
times between 4/11/19 and 4/17/19 (the controlled sheet showed 12).
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 21)
-The administration was initialed five times on the front of the MAR.
-The time of the administration was documented two out of five times on the front of the
MAR and
-The administration was documented on the back of the MAR three times.
During an interview on 4/19/19 at 10:56 A.M., the Director of Nursing (DON) said:
-The administration of the medication should be the same on the MAR as it is on the
controlled sheet and
-The nurse’s should document a pain scale rating, the medication administered, the dose of
the medication administered, the location of the pain, any non-medication interventions
attempted and they should follow up and document the effectiveness of the medication.
2. Record review of Resident #71’s face sheet showed he/she was admitted to the facility
on [DATE]. The resident’s current [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] Disorder
(a chronic mental health condition characterized primarily by symptoms such as
hallucinations or delusions, and symptoms of a mood disorder).
-[MEDICAL CONDITION] ([MEDICAL CONDITION] – a lung disease characterized by chronic
obstruction of lung airflow that interferes with normal breathing).
-Chronic [MEDICAL CONDITION] (a condition characterized by a gradual loss of kidney
function over time).
-[MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease that causes restricted blood flow to
the arms, legs, or other body parts).
-[MEDICAL CONDITION] (A-Fib – a quivering or irregular heartbeat (arrhythmia) that can
lead to blood clots, stroke, heart failure and other heart-related complications).
-Generalized Anxiety Disorder (persistent and excessive worry about a number of different
things).
-[MEDICAL CONDITION] Mood Disorder (a mental health condition that causes extreme mood
swings) and
-Intellectual Disability (a disability characterized by significant limitations both in
intellectual functioning (reasoning, learning, problem solving) and in adaptive behavior,
which covers a range of everyday social and practical skills).
Record review of the resident’s Annual MDS dated [DATE], showed he/she:
-Was cognitively able to make decisions regarding tasks of daily living.
-Needed limited assistance with bed mobility, walking, locomotion, and personal hygiene.
-Needed extensive assistance with transfers and dressing.
-Needed only setup with eating.
-Required total assistance with toilet use and bathing.
-Was always incontinent of bowel and bladder and
-Received antipsychotic, antianxiety, antidepressant, anticoagulant and diuretic
medications daily.
Record review of the resident’s POS dated (MONTH) 2019 showed the following order: Fluid
Restriction 1800 CC (cubic centimeter – volume inside a cube in which each edge measure
one centimeter: equivalent of one milliliter (ml) per day. Please show every shift and MLs
on MAR. The order was dated 10/24/18.
Record review of the resident’s MAR for 4/1/19 to 4/30/19, showed:
-A miscellaneous order: Fluid Restriction 1800 CC per day. Please show every shift and MLs
on MAR.
-There were initials daily on each shift and
-There was no documentation showing the amount of fluids the resident received.
Observation of the resident on 4/11/19 at 9:00 A.M. showed he/she:
-Was in the dining area of the Alzheimer’s Unit, finishing his/her breakfast.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
-Ate and drank 100% of his/her food and drinks and
-Had juice, water and a drink from a cup of coffee.
During an interview on 4/19/19 at 9:47 A.M., Certified Medication Technician (CMT) D said:
-We don’t document the amount of fluids the resident gets and
-The nurse may be doing the documenting of his/her fluids.
During an interview on 4/19/19 at 9:53 A.M., Licensed Practical Nurse (LPN) A said:
-There was no order on the nurse MAR for them to document the resident’s fluid intake and
-Usually dietary would handle getting the resident his/her drinks in the right amount when
the resident was on a fluid restriction.
During an interview on 4/19/19 at 10:10 A.M., the Dietary Manager said:
-He/She was aware of the resident’s fluid restriction.
-The fluid restriction is noted on the resident’s ticket.
-The resident and the staff serving drinks had been educated on the fluid restriction.
-Drinks are served in 4 ounce or 8 ounce cups.
-The resident is allowed an 8 ounce drink serving at meal time and
-Dietary staff do not document anything in relation to the order on the resident’s MAR.
Nursing would be responsible for documenting on the resident’s MAR.
3. Record review of Resident #71’s POS dated (MONTH) 2019 showed an order for [REDACTED].
Record review of the resident’s PRN medication MAR showed:
-The order for the resident to receive [MEDICATION NAME] Tablets, 650 mg every six hours
PRN for pain or fever.
-The resident was administered the medication on the following dates:
–4/3/19 at 11:50 A.M.
–4/4/19 at 8:00 A.M.
–4/8/19 at 12:00 P.M.
–4/9/19 at 12:00 P.M.
-There was no documentation to show why the resident received the medication and
-There was no documentation to show the results of the medication.
During an interview on 4/19/19 at 9:54 A.M., LPN A said:
-The medication was administered prior to the resident moving from the Alzheimer’s Unit.
-There should have been documentation to show why the resident received the medication and
-There should also be documentation to show if the medication was effective.
4. During an interview on 4/19/19 at 10:56 A.M., the DON said:
-If there was an order for [REDACTED].
-Nursing staff would be responsible for documenting the resident’s fluid intake as ordered
by the physician.
-If a resident was given a PRN medication he/she would expect to see documentation
showing:
–Why the medication was given to the resident and
–The follow-up results, showing the condition of the resident after the medication was
given.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to ensure ongoing
resident centered activities, as well as one on one activities for residents not

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
participating in group activities, were provided as an integral part of the psychosocial
well-being for residents residing on the Alzheimer’s (progressive mental deterioration due
to generalized degeneration of the brain) Unit, for three sampled residents (Residents
#70, #71 and #99), out of 23 sampled residents. The facility census was 113 residents.
1. Record review of Resident #70’s face sheet showed he/she was admitted to the facility
2/15/19 and his/her [DIAGNOSES REDACTED].
-[MEDICAL CONDITION] (decline in mental ability caused by an impaired supply of blood to
the brain).
-Diabetes Mellitus (a long-term metabolic disorder characterized by high blood sugar,
insulin resistance, and relative lack of insulin) and
-Subarachnoid Hemorrhage (a life-threatening type of stroke caused by bleeding into the
space surrounding the brain).
Record review of the resident’s Admission Minimum Data Set (MDS a federally mandated
assessment tool to be completed by facility staff for care planning) dated 2/21/19, showed
he/she:
-Was cognitively impaired.
-Needed limited physical assistance with bed mobility and transfers.
-Needed extensive assistance with dressing and toileting.
-Was independent with eating.
-Was interviewed for daily and activity preferences. Daily and activity preferences that
were very important to the resident included:
–Having snacks available between meals.
–Having family involved in discussions about his/her care.
–Listening to music he/she liked.
–Keeping up with the news.
–Doing his/her favorite activities and
–Going outside to get fresh air when the weather is good.
Record review of the resident’s care plan initiated 2/25/19 and revised 3/4/19, showed:
-The resident’s interests included cards, movies, and sport material.
-The goal was for the resident to be able to make recreation and leisure preferences
known.
-Interventions included the resident:
–Would attend all programs of interest.
–Would pursue independent activities of choice and
–Would have exposure to a variety of group activities.
During an interview on 4/11/19 at 1:06 P.M., the resident’s family member said:
-The resident used to play Bingo, go on outings and participate in some of the other
activities at his/her former place of residence.
-He/she had not seen any activities taking place since the resident moved to this
facility, and the resident had not mentioned any activities and
-The resident would have definitely mentioned it if he/she had participated in any
activities.
Observation of the resident on 4/16/19 at 11:30 A.M. showed the resident sitting in
his/her wheelchair in the doorway of his/her room.
-The Activities Aide went to the resident and asked if he/she wanted to do exercises and
-The resident said not now, and the Activities Aide continued down the hall.
2. Record review of Resident #71’s face sheet showed he/she was admitted to the facility
on [DATE]. The resident’s current [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] Disorder
(a chronic mental health condition characterized primarily by symptoms such as
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
hallucinations or delusions, and symptoms of a mood disorder).
-[MEDICAL CONDITION] ([MEDICAL CONDITION] – a lung disease characterized by chronic
obstruction of lung airflow that interferes with normal breathing).
-Generalized Anxiety Disorder (persistent and excessive worry about a number of different
things).
-[MEDICAL CONDITION] Mood Disorder (a mental health condition that causes extreme mood
swings) and
-Intellectual Disability (a disability characterized by significant limitations both in
intellectual functioning (reasoning, learning, problem solving) and in adaptive behavior,
which covers a range of everyday social and practical skills).
Record review of the resident’s Annual MDS dated [DATE], showed he/she:
-Was cognitively able to make decisions regarding tasks of daily living.
-Needed limited assistance with bed mobility, walking, locomotion, and personal hygiene.
-Needed extensive assistance with transfers and dressing.
-Required total assistance with toilet use and bathing.
-Was interviewed for daily and activity preferences. Daily and activity preferences that
were very important to the resident included:
–Having snacks available between meals.
–Having family involved in discussions about his/her care.
–Being around animals such as pets.
–Doing things with groups of people.
–Keeping up with the news.
–Doing his/her favorite activities and
–Participating in religious services or practices.
Record review of the resident’s Care Plan Summary Progress Note dated 2/28/19, showed:
-The resident attended the Care Plan Meeting.
-The resident said he/she would like to see more activities like Bingo, Checkers and other
different kinds of activities and
-The resident said he/she watches television a lot.
Observation on 4/11/19 at 11:10 A.M., showed the resident participating in an activity.
The residents were making small pillows and the Activities Aide was facilitating.
Observation and interview on 4/11/19 at 11:17 A.M., staff members were observing the
residents participating in the activity:
-Certified Medication Aide (CMT) D said:
–The residents are so calm right now doing this activity.
–This is very different.
–There are usually no activities on this unit.
–He/she thought having activities on a regular basis would be calming for the residents
and
–It would give them something to do.
During an interview on 4/11/19 at 11:40 A.M., after the residents finished making their
pillows, the resident said:
-He/she just made a pillow.
-Having an activity was really nice.
-It does not happen often.
-There have not been activities on the unit, but he/she gets to go off the unit and do
therapy and
-There are usually no activities in the area (referring to the Alzheimer’s Unit).
Observation and interview on 4/11/19 at 11:47 A.M., the Activities Aide left the unit and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
returned within a few minutes.
– The resident asked the Activities Aide when he/she would return and the Activities Aide
said he/she would return at 2:30 to bring ice cream.
-The Activities Aide said:
–Normally they did not get a chance to come back on the Alzheimer’s Unit for regular
activities because they were short of staff.
–It was only him/her and his/her boss doing activities for the entire building.
–When he/she came back to the unit it was usually only to bring daily snacks.
–He/she only came to that unit for activities involving food and
–There were no one-on-one activities for residents who did not attend the group
activities.
3. Record review of Resident #99’s face sheet showed he/she was admitted to the facility
on [DATE]. The resident’s current [DIAGNOSES REDACTED].>-Diabetes Mellitus.
-Major [MEDICAL CONDITION] (a mood disorder that causes a persistent feeling of sadness
and loss).
-[MEDICAL CONDITION] Disorder (a mental illness that causes dramatic shifts in a person’s
mood, energy and ability to think clearly) and
-Convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by
involuntary contraction of muscles and associated especially with brain disorders).
Record review of the resident’s Annual MDS dated [DATE], showed he/she:
-Was cognitively able to make decisions regarding tasks of daily living.
-Needed minimal assistance with bed mobility, transfers, locomotion, dressing, toilet use,
and personal hygiene.
-Had functional impairment of both lower extremities.
-Was always continent of bowel and bladder.
-Was interviewed for daily and activity preferences. Daily and activity preferences that
were very important to the resident included:
–Choosing the clothes he/she wore.
–Taking care of his/her personal belongings.
–Choosing the type of bath he/she had.
–Choosing his/her bedtime and
–Going outside to get fresh air when the weather was good.
Record review of the resident’s Quarterly MDS dated [DATE], showed he/she:
-Was cognitively able to make decisions regarding tasks of daily living.
-Was independent with bed mobility, transfers, locomotion, dressing, toilet use, and
personal hygiene.
-Was always continent of bowel and bladder and
-Had functional impairment of both lower extremities.
Record review of the resident’s Care Plan Summary Progress Note dated 3/26/19, showed:
-He/she attended the meeting and
-The activities staff reported the resident attended activities of his/her choice.
During an interview on 4/11/19 at 2:59 P.M., the resident said:
-He/she is no longer allowed to go out to the main area of the facility to participate in
activities.
-The only time he/she goes off the unit is to go to therapy.
-Every now and then he/she used to get to go to the activity that was at 7:30 P.M. and to
a 10:30 A.M. Saturday morning activity that he/she really enjoyed and
-He/she no longer gets to go off the unit to attend those activities.
During an interview on 4/16/19 at 9:39 A.M., the resident said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
-He/She was not told about the activities that took place yesterday when an activities
staff person from a sister facility came to assist with activities on the Alzheimer’s
Unit.
-He/She would like to see Bingo games and something like a game night on their unit.
-No one ever comes and talks to him/her one on one and
-The only activity he/she has seen on their unit is when staff bring ice cream to them.
The person bringing the ice cream back will usually come and tell them they are getting
ready to serve them ice cream.
During an interview on 4/19/19 at 10:56 A.M., the Director of Nursing (DON) said:
-He/she would have expected activities to be taking place on a consistent basis for
residents residing on the Alzheimer’s Unit and
-There should have been one on ones for residents.

F 0685

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assist a resident in gaining access to vision and hearing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to schedule an
ophthalmologist (a physician who specializes in the treatment of [REDACTED].#67) out of 23
sampled residents. The facility census was 113 residents.
Record review of the facility’s consultation policy dated (MONTH) (YEAR) showed:
-A physician’s orders [REDACTED].
-A licensed nurse obtains a physician order [REDACTED].>1. Record review of Resident
#67’s 2/5/19 vision exam showed the plan was to consult with an ophthalmologist.
Record review of the resident’s annual Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 2/20/19 showed the
following staff assessment of the resident:
-Was cognitively intact.
-Had adequate vision and
-Was not wearing corrective lenses during the assessment.
Record review of the resident’s care plan dated 2/20/19 showed the resident’s vision
impairment and the use of glasses were not included in the care plan.
Record review of the resident’s medical records showed no documentation regarding
following up with an appointment with an ophthalmologist.
Observation and interview on 4/12/19 at 9:22 A.M., showed the resident:
-Was wearing glasses.
-When he/she went to his/her eye appointment, he/she was told he/she needs to see an
ophthalmologist and
-He/she asked about getting an ophthalmologist appointment but no one made an appointment
for him/her.
During an interview on 4/16/19 at 11:53 A.M., the Director of Nursing (DON) said:
-The nurse should call the resident’s primary care physician to request a referral for the
ophthalmologist and
-After a referral for the ophthalmologist from the resident’s primary care physician is
obtained, then the nurse should schedule the ophthalmologist appointment.
During an interview on 4/18/19 at 10:49 A.M., the Social Worker said:
-It used to be Social Services that received the ancillary progress notes for scheduling
follow-up appointments.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0685

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
-The facility did not have a Social Worker at the time of the resident’s vision exam
(2/5/19) and
-He/She did not start working at the facility until the end of (MONTH) 2019.
During an interview on 4/19/19 at 11:48 A.M., the DON said:
-The optometrist gives all of his/her papers to the Social Worker after examining
residents.
-The Social Worker should make any new appointments necessary included in the
optometrist’s notes and
-If the Social Worker is not going to make the appointments, he/she needs to let nursing
know so they can make the appointments.

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility staff failed to ensure an
alternating pressure reducing mattress was in good repair; to obtain physician’s orders
for the alternating pressure reducing mattress; to maintain the mattress on the correct
settings for one sampled resident (Resident #309) who was admitted with pressure ulcers
(localized injury to the skin and/or underlying tissue usually over a bony prominence, as
a result of pressure, or pressure in combination with shear and/or friction); and to
ensure the specialty mattress was at the proper weight setting for one sampled resident
(Resident #83) out of 23 sampled residents. The facility census was 113 residents.
Record review of the facility’s Support Surfaces policy dated 4/2019 showed:
-Redistributing support surfaces were to promote comfort for all bed or chair bound
residents, prevent skin breakdown, promote circulation and provide pressure relief of
reduction.
-All beds (air mattresses) that have adjustable settings, generally based on weight or
firmness overlay that have adjustable settings, generally based on weigh or firmness would
be monitored to ensure the correct setting and
-If settings were represented by a single weigh number, the number closest without going
over would be used.
1. Record review of Resident #309’s Face Sheet showed he/she was admitted to the facility
on [DATE] for skilled services and had the following Diagnoses: [REDACTED]. Subcutaneous
fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but
does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling).
-Non-pressure chronic ulcer of the back with necrosis (dead tissue) of the bone; and
-[MEDICAL CONDITION] (loss of movement of both legs and generally the lower trunk).
Record review of the resident’s Physician’s Orders Sheet (POS) dated 4/4/19 showed:
-There were no physician’s orders for the alternating pressure reducing mattress settings;
and
-There were no physician’s orders showing how often to monitor the resident’s alternating
pressure reducing mattress.
Record review of the resident’s baseline care plan dated 4/4/19 showed:
-The resident was admitted to the facility with wounds; and
-The resident was admitted with the use of a wound vac (a machine used to treat advanced
bed sores. A pump is then attached to this area to draw moisture from the wound itself.
The pump acts as a vacuum to draw the excess fluids from the wound and collect them into a

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
chamber).
Record review of the resident’s weight record showed no weights were taken at the facility
for the resident.
During an interview on 4/11/19 at 9:20 A.M. the resident said:
-He/she was admitted with the pressure ulcers and the wound vac care at the facility was
going very well; and
-He/she was also being seen for his/her pressure ulcers at a wound clinic and had a
physician overseeing the care of his/her pressure ulcers.
Observation on 4/11/19 at 9:20 A.M. showed:
-The resident’s alternating pressure reducing mattress was set at a weight of 350 pounds;
and
-The resident’s alternating pressure reducing mattress had an area in the middle of the
mattress where the mattress was not inflating and the resident could put his/her arm down
into the mattress.
Observation on 4/11/19 at 1:31 P.M. showed:
-The resident’s alternating pressure reducing mattress was set at a weight of 350 pounds;
and
-The resident’s alternating pressure reducing mattress had an area in the middle of the
mattress where the mattress was not inflating and the resident could put his/her arm down
into the mattress.
During an interview on 4/12/19 at 9:32 P.M. the resident said:
-He/she weighed 146 pounds;
-The mattress was very uncomfortable and he/she fell in when he/she was lying on it; and
-He/she had told different staff the mattress was not in good repair but the mattress had
not been changed.
Observation on 4/12/19 at 9:32 P.M. showed:
-The resident’s alternating pressure reducing mattress was set at a weight of 350 pounds
with alternating air pressure every ten minutes; and
-The resident’s alternating pressure reducing mattress had an area in the middle of the
mattress where the mattress was not inflating on one area on the right side midway down
the mattress.
Observation on 4/15/19 at 8:12 A.M. showed:
-The resident was lying on his/her back in bed; and
-The his/her alternating pressure reducing mattress was set at a weight of 350 pounds with
alternating air pressure every ten minutes.
During an interview on 4/16/19 at 10:21 A.M. Certified Nursing Assistant (CNA) C said:
-The nurse was responsible for ensuring the resident’s alternating pressure reducing
mattress was set correctly;
-He/she had not noticed the resident’s mattress was not inflating on one area; and
-The nurses would check for issues with the low air loss mattress but CNA’s should monitor
also for inflation issues.
During an interview on 4/16/19 at 10:31 A.M. Licensed Practical Nurse (LPN) D said:
-Central Supply and maintenance set up the alternating pressure reducing mattresses;
-The nurses were responsible for making sure the setting are correct;
-The mattress should be set by weight if there was a weight setting on it;
-The nurse was responsible for obtaining the physician’s orders for the mattress from the
hospital or physician;
-The settings should be on the POS and the resident’s Medication Administration Records
(MARs); and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
-Nurses monitor to ensure the residents’ mattress was in good repair along with CNA’s.
During an interview on 4/16/19 at 11:47 A.M., CNA C said:
-The CNA’s do not do anything with settings of alternating pressure reducing mattresses;
-The nurses were responsible for ensuring the settings were correct; and
-If a mattress was not in good repair, he/she would notify the charge nurse.
During an interview on 4/18/19 at 10:07 A.M., CNA F said:
-He/she did not monitor or adjust settings to alternating pressure reducing mattresses;
and
-He/she was unsure who monitors the mattresses.
During an interview on 4/18/19 at 11:04 P.M. LPN A said:
-The nurses were responsible for obtaining the physician’s orders for the alternating
pressure reducing mattresses;
-This should be documented by the nurse on the resident’s POS;
-The CNA’s were responsible for reporting mattresses that were not in good repair to the
nurses; and
-The resident had pressure ulcers and needed an alternating pressure reducing mattress for
healing the wounds and further prevention of the wounds.
During an interview on 4/19/19 at 10:57 A.M., the Director of Nursing (DON) and Corporate
Nurse C said:
-Central supply would set up the mattresses for the residents;
-The facility did not have a system in place for monitoring the alternating pressure
reducing mattress for the residents’;
-The mattresses should be set by weight;
-The resident should have been weighed upon admission by the nurse and determine the
correct settings for the mattress;
-The mattress should have been set correctly to aide in healing of the resident’s pressure
ulcers; and
The resident had extensive wounds.
2. Record review of Resident #83’s face sheet showed he/she was admitted to the facility
on [DATE]. The resident’s current [DIAGNOSES REDACTED].>-Diabetes Mellitus (a long-term
metabolic disorder characterized by high blood sugar, insulin resistance, and relative
lack of insulin).
-[MEDICAL CONDITION] (a medical condition in which the bones become brittle and fragile
from loss of tissue).
-Dementia (a general term for a decline in mental ability severe enough to interfere with
daily life) and
-Anxiety Disorder (repeated episodes of sudden feelings of intense anxiety and fear or
terror that reach a peak within minutes).
Record review of the resident’s Significant Change Minimum Data Set ((MDS) dated [DATE],
showed he/she:
-Was moderately impaired for making decisions regarding task of daily life, and cues and
supervision was required.
-Required extensive assistance with bed mobility, transfers, and locomotion.
-Was totally dependent on staff with dressing, toilet use, personal hygiene, and bathing.
-Was frequently incontinent of bowel and bladder.
-Received a mechanically altered diet and
-Was at risk of developing pressure ulcers.
Record review of the resident’s Electronic Medical Record showed:
-The resident was hospitalized [DATE] through 3/15/19.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
-Upon readmission to the facility, the resident was also readmitted to Hospice Care on
3/15/19 and
-The resident’s weight was 117 pounds.
Record review of the resident’s Significant Change MDS, dated [DATE], showed the resident:

-Was severely impaired cognitively.
-Required extensive assistance with bed mobility, transfers, and locomotion.
-Was totally dependent on staff with dressing, toilet use, personal hygiene, and bathing.
-Was always incontinent of bowel and bladder.
-Had a condition or chronic disease that may result in a life expectancy of six months or
less.
-Was at risk of developing pressure ulcers.
-Had one unstageable pressure ulcer with suspected deep tissue injury in evolution and
-Had the unstageable pressure ulcer upon re-entry to the facility.
Record review of the resident’s most recent Care Plan showed:
-The resident was receiving hospice care.
-Staff was to monitor the resident’s weight per facility protocol or physician’s order.
-Staff was to administer medications and treatments per the physicians’ orders and
-There was not an update to show the resident’s current interventions related to his/her
wound.
Observation on 4/11/19 at 12:54 P.M. of the resident’s room showed:
-The resident had a Low Air Loss Mattress (LALM – a mattress with tiny laser made air
holes in the top surface that continually blow out air causing the patient to float; a
preferred method of treatment and prevention of skin ulcers) and
-The LALM weight setting was set on 180 pounds.
Record review of the resident’s Weekly Wound Assessment, dated 4/11/19, showed:
-The resident had one wound.
-The wound was located on the resident’s left heel.
-Interventions included repositioning, heels raised while in bed, bony prominences padded,
a specialty mattress, and additional supplements as ordered.
-Staff was to provide the following treatment:
–Cleanse area to the resident’s left heel with wound cleanser.
–Pat dry.
–Apply skin prep and dry dressing daily and as needed.
-The wound was improved.
Observation on 4/15/19 at 7:55 A.M. showed the resident was sitting in his/her Broda Chair
(a high-back tilt-in-space positioning wheelchair) at the dining table. He/she was wearing
protective boots on both feet and legs.
Observation of the resident in his/her bed on 4/16/19 at 11:45 P.M. during wound care
showed the resident’s LALM weight setting was on 180 pounds.
Observation on 4/18/19 at 10:46 A.M. showed the resident’s LALM weight setting was set on
180 pounds.
During an interview on 4/18/19 at 10:47 A.M., CNA J said:
-He/She thought Central Supply was responsible for checking mattresses.
-He/She did not know what the resident’s LALM should be set on and
-He/she would let Central Supply know if there is a problem with mattresses.
During an interview on 4/18/19 at 10:52 A.M. Certified Medication Technician (CMT) D said:

-The bath aides weigh the residents and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
-He/She did not know who was responsible for checking the resident’s LALM weight setting.
During an interview on 4/18/19 at 10:57 A.M. LPN J said:
-Nursing usually checks the LALM settings on a daily basis.
-He/She would have to check the resident’s medical record to see what his/her weight was.
-After finding out the resident’s weight was 117 pounds, he/she changed the setting on the
resident’s LALM and
-He/she would check to see if there was a note or any kind of order related to the
resident’s LALM.
During an interview on 4/19/19 at 10:56 A.M., the DON said:
-Central Supply normally goes in and sets the bed settings after a bed has been delivered.
-There is nothing in place for monitoring the appropriate setting according to the
resident’s weight and
-During the interview the Corporate Registered Nurse (RN) B said it should be the nurses
that are going in and monitoring the setting on the residents’ LALMs.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
restorative services were provided to maintain, improve, or prevent decline in range of
motion for one sampled resident (Resident #62) out of 23 sampled residents. The facility
census was 113 residents.
Record review of the facility’s Rehabilitative Nursing Care revised 4/2019 showed:
-Rehabilitation nursing care was provided for each resident admitted .
-Nursing personnel were trained in rehabilitative nurses’ care. Our facility has an active
program of rehabilitative nursing which was developed and coordinated through the
residents care plan; and
-Assist residents with their routine range of motion exercises.
1. Record review of Resident #62’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] disease (refers to a group of conditions that can lead to a [MEDICAL
CONDITION] event, such as a stroke. These events affect the blood vessels and blood supply
to the brain. If a blockage, malformation, or hemorrhage prevents the brain cells from
getting enough oxygen, brain damage can result).
Record review of the resident’s Care Plan revised 11/8/18 showed he/she:
-Had a left upper extremity contracture (an abnormal usually permanent condition of a
joint, characterized by flexion and fixation).
-Needed a hand splint applied to his/her left hand contracture; and
-Was on hospice (end of life care) related to a [DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by facility staff for care planning) dated
2/21/19 showed he/she:
-Was cognitively intact.
-Had limitations with range of motion on one upper and lower side (arm and leg); and
-Needed the assistance of one staff member with transfers, and bed mobility.
Record review of the resident’s physician progress notes [REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
-Had a [DIAGNOSES REDACTED].
-Had a left upper extremity contracture.
Record review of the resident’s Physician’s Orders Sheet (POS) dated 3/2019 showed there
were no physician’s orders related to range of motion or for the resident’s hand splint.
During an interview and observation on 4/11/19 11:13 A.M., the resident said:
-He/she had a stroke.
-He/she had a hand split but it hurt to wear it on his/her left hand.
-The staff were supposed to be doing range of motion with his/her left hand but have not
done range of motion on his/her hand for months.
-He/she would have to ask the staff to help open his/her left hand; and
-The resident’s left hand was contracted into a fist position.
Observation on 4/16/19 at 8:29 A.M. showed the resident was in the dining room and had a
splint on his/her left hand.
Observation on 4/16/19 at 11:35 A.M. showed:
-The resident was being assisted by a staff member during a transfer.
-The resident was able to hold onto a transfer pole with his/her right hand and stand up
bearing full weight to his/her feet; and
-The resident had the hand splint on his/her left hand.
During an interview on 4/18/19 at 9:52 A.M. Certified Medication Technician (CMT) C said:
-He/she was unsure which staff member was responsible for restorative services.
-He/she did not believe any staff member was assigned to complete range of motion for the
residents’; and
-The resident did have left hand contractures and would put his/her hand splint on and off
at times.
During an interview on 4/18/19 at 10:01 A.M. Corporate Nurse C (also a Registered
Nurse-RN) said:
-The facility did not have a restorative program for range of motion.
-Certified Nursing Assistants (CNA) were instructed to continue range of motion for the
residents after the resident was discharged from therapy; and
-CNAs should be completing range of motion for the residents.
During an interview on 4/18/19 at 10:04 A.M., the Therapy Director said:
-The resident had not been seen in the past year for his/her left hand contracture; and
-The resident was on hospice and therapy did not work with residents’ who were on hospice.
During an interview on 4/18/19 at 10:07 A.M. CNA F said:
-He/she had not completed range of motion on the resident’s left hand.
-He/she was unsure who placed the resident’s brace of his/her left hand, maybe therapy put
the brace on the resident’s left hand; and
-He/she had never been instructed to complete range of motion for the resident.
During an interview on 4/18/19 at 11:04 A.M., Licensed Practical Nurse (LPN) A said:
-The facility did not have a restorative program for the residents.
-The resident should have physician’s orders for the use of the hand splint and for
restorative services; and
-The resident was not receiving range of motion for his/her left hand contracture.
During an interview on 4/19/19 at 10:57 A.M., the Director of Nursing (DON) and Corporate
Nurse B said:
-The facility did not have a restorative program.
-Daily resident care would cover the Activities of Daily Living (ADLS-dressing, bathing,
and grooming).
-If the resident had a decline, he/she would have therapy assess the resident.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 33)
-The therapy department monitors residents’ with contractures.
-He/she expected the nurses to obtain physician’s orders for the resident’s left hand
splint; and
-Therapy had not been seeing the resident due to the resident’s hospice status.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure resident safety during
a facility van transport due to the seat belt not being fastened properly for one sampled
resident (Resident #78) out of 23 sampled residents. The facility census was 113
residents.
Record review of the facility’s policy titled Facility Provided Transportation dated
3/2019 showed:
-Only approved facility employees designated as facility Transportation Driver will
operate the van.
-The facility Transportation Driver will be approved to drive the van/bus only after
reviewing and signing the Van Driver job description, reviewing this policy, completing
Transportation Driver orientation curriculum, and proving role competency covering van use
and safety performance, verified and signed by the Administrator.
-A Certified Nursing Assistant (CNA) or activity assistant, with the understanding of the
van attendant/safety responsibilities, as laid out in this policy, will accompany
residents and serve as attendant, on medical appointments as indicated.
-The Transportation Driver secures wheelchairs to the transportation van/bus to stabilize
the assisted devices during the trip.
-Ensures that resident/patients are secured with lap belts or seatbelts.
-The Transportation Driver will not move the van/bus until everyone is secured and belted
and ensures that passengers are wearing seat belts at all times, while the van/bus is
being operated.
-The Transportation Driver attends and participates in facility in-service training, and
other continuing education, career and professional development opportunities.
-The attendant will assist the driver to secure the wheelchairs in the van/bus; and
-All residents, attendants, and the driver are to use seat belts while the van is in
motion.
1. Record review of Resident #78’s face sheet showed he/she was admitted on [DATE] with
the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (any abnormal condition of the structure or function of brain
tissues, especially chronic, destructive, or [MEDICAL CONDITION] conditions); and
-[MEDICAL CONDITION] (a medical condition in which excess body fat has accumulated to the
extent that it can result in many serious, potentially life-threatening health problems).
Record review of the resident’s nurses notes dated 3/26/19 at 4:01 P.M. showed:
-Nurses were notified at 10:45 A.M. that resident had slid out of his/her wheelchair while
in the van.
-The resident was taken to the hospital for evaluation, and was on the way back to the
facility.
-The resident had no new orders from the hospital; and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 34)
-The resident was currently resting in bed comfortably.
During an interview on 4/16/19 at 1:34 P.M. the Transport Driver said he/she:
-Used the lift to get residents and wheelchairs into the van.
-Secured the wheelchair to the floor with straps (four locks total).
–Two on the cross bars under the seat.
–Two on the up-right bars on the back of the wheelchair.
-Twisted the straps to tighten and lock.
-Fastened the seat belt and then the shoulder harness around residents.
-Did not hear the click of the seat belt fastening but thought the belt was fastened.
-Made a sudden stop when a city road worker entered the road and signaled the driver to
stop.
-The resident slid out of the wheelchair on to the van floor.
-At that time, he/she knew the seat belt was not properly secured.
-At the time of the incident:
–He/she did not know the resident was not properly buckled in on the van; and
–He/she did not know the van was missing a part.
During an interview on 4/18/19 at 11:10 A.M. the Director of Nursing (DON) said:
-On 3/26/19 the resident was on the way to a physician’s appointment.
-Resident slid out of the wheelchair onto the van floor.
-He/she expected residents and other occupants to be secured by seat belts and shoulder
harnesses and
-He/she was not sure if the Transportation Driver had been educated on the proper use of
the seat belt and shoulder harness;
During an interview on 4/19/19 at 10:57 A.M. the DON said:
-The van driver is not a Certified Nursing Assistant (CNA).
-The van driver had not had any documented training prior to the incident, including:
–How to strap a resident in.
–How to check the seatbelt.
-When a resident cannot be secured; the van is not used.
-Since the incident the facility has ordered a missing part for the van; and
-The van was not being used per administration.
MO 650

F 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that feeding tubes are not used unless there is a medical reason and the
resident agrees; and provide appropriate care for a resident with a feeding tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure that an
enteral feeding (tube feeding-the delivery of a nutritionally complete food, containing
protein, carbohydrate, fat, water, minerals, and vitamins, directly into the stomach) was
administered as ordered for one sampled resident (Resident #40) out of 23 sampled
residents. The facility census was 113 residents.
Record review of the facility’s policy titled Enteral Nutrition Feedings with a revised
date of (MONTH) 2019 showed:
-To provide enteral nutrition therapy to residents unable to obtain nutrition orally, when
such therapy is ordered by the physician and not clinically contraindicated.
-Intermittent (occurring at irregular intervals, not continuous or steady) enteral feeding

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 35)
is delivered over a specific period of time or until a specified volume of formula is
delivered.
-Verify the physician’s orders [REDACTED].>-Use electronic delivery pump whenever
feasible and according to policy.
1. Record review of Resident #40’s Admission Record showed that he/she admitted on [DATE]
and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (paralysis of all four extremities and usually the trunk) and
-[MEDICAL CONDITION] status (surgical opening into the wind pipe into which a tube is
inserted to allow passage of air and removal of secretions)
Record review of the resident’s Care Plan showed the resident:
-Required tube feeding goal:
–Will maintain adequate nutritional and hydration status.
–Will maintain stable weight.
–Will have no signs/symptoms of malnutrition or dehydration through review date of
5/6/19.
-Tube feeding interventions:
–Administer tube feeding and water flushes per Registered Dietitian and Licensed
Dietitian (RDLD) and Physician orders.
Record review of the resident’s Physician order [REDACTED].
-[MEDICATION NAME] (nutritional supplement) 1.2 liquid calories (cals).
–Infuse at 85 milliliters (ml) per hour times 20 hours.
–Off from 10:00 A.M. to 2:00 P.M. daily.
–Order start date of 2/21/19 and
-Water flush infuse at 160 mls every six hours.
Record review of the resident’s Medication Administration Record [REDACTED]
-[MEDICATION NAME] 1.2 liquid cals at 85 ml/hour times 20 hours and
–Off from 10:00 A.M. to 2:00 P.M. daily.
Observation on 4/16/19 at 9:38 A.M., of the resident’s cares showed:
-Tube feeding of the [MEDICATION NAME] 1.2 cals completed infusing.
-The infusion delivery pump alarming and
-A nurse entered the room and turned the machine off and said he/she would be back.
Observation on 4/16/19 at 10:40 A.M., showed:
-A new container of the [MEDICATION NAME] 1.2 cals hanging and infusing and
-The container was dated 4/16/19 at 10:00 A.M.
Observation on 4/18/19 at 10:04 A.M., showed:
-A container of the [MEDICATION NAME] 1.2 cals hanging and infusing and
-The container was dated 4/18/19 at 5:00 A.M.
During an interview on 4/18/19 at 10:22 A.M., Licensed Practical Nurse (LPN) F said:
-The facility had several residents who received tube feedings.
-Some of the resident’s who received tube feeding had a two to four hour time frame where
they do not receive the tube feedings daily and
-He/she checked on his/her tube feeding residents about every two hours to be sure the
feedings are infusing correctly.
Observation on 4/18/19 at 11:49 A.M., showed:
-A container of the [MEDICATION NAME] 1.2 cals hanging and infusing and
-The container was dated 4/18/19 at 5:00 A.M.
During an interview on 4/19/19 at 10:55 A.M., the Director of Nursing (DON) said:
-He/she would expect the nurses to follow the Physicians orders and
-He/she would not expect a tube feeding to be infusing during the times that the order
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 36)
specified not to.

F 0694

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide for the safe, appropriate administration of IV fluids for a resident when
needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to change a
Peripherally Inserted Central Catheter (PICC line- a thin, soft, long catheter (tube) that
is inserted into a vein in the arm, leg or neck. The tip of the catheter is positioned in
a large vein that carries blood into the heart. The PICC line is used for long-term
intravenous (IV) antibiotics, nutrition or medications, and for blood draws) dressing and
to create a baseline care plan for the PICC line for one sampled resident (Resident #309)
out of 23 sampled residents. The facility census was 113 residents.
1. Record review of Resident #309’s Face Sheet showed he/she was admitted to the facility
on [DATE] for skilled services and had the following Diagnoses: [REDACTED]. Subcutaneous
fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but
does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling).
-Non-pressure chronic ulcer of the back with necrosis (dead tissue) of the bone; and
-[MEDICAL CONDITION] (loss of movement of both legs and generally the lower trunk).
Record review of the resident’s physician’s orders [REDACTED].
Record review of the resident’s baseline care plan dated 4/5/19 showed there was no care
plan for the resident’s PICC line.
Record review of the resident’s skin/wound note dated 4/5/19 showed:
-The resident had non-healing chronic pressure ulcers (localized injury to the skin and/or
underlying tissue usually over a bony prominence, as a result of pressure, or pressure in
combination with shear and/or friction); and
-The resident was being treated with intravenous (process of giving medication directly
into a resident’s vein) medication for wound infections.
Record review of the resident’s undated Treatment Administration Record (TAR)showed:
-A physician’s orders [REDACTED].
–There was no documentation that showed the resident’s PICC line dressing had been
changed on 4/5/19 or on 4/12/19.
During an interview and observation on 4/15/19 at 8:17 A.M. showed:
-The resident had a PICC line in his/her left upper, inner arm.
-The PICC line dressing was not dated and had brownish dirt on the edge of the bottom of
the dressing.
-The lower part of the PICC line dressing was lifting up from the resident’s skin; and
-The resident said the last time the PICC line dressing had been changed was before
his/her admission to the facility.
During an interview on 4/15/19 at 8:30 A.M., Licensed Practical Nurse (LPN) A said:
-The resident’s PICC line dressing was soiled and was not dated.
-The dressing should be changed by a Registered Nurse (RN) weekly and as needed; and
-When the dressing was changed, the nurse was supposed to date the PICC line dressing.
During an interview on 4/16/19 at 10:13 A.M. LPN D said:
-He/she thought the electronic medical record generated a baseline care plan.
-He/she was unsure who created/updated the baseline care plans; and
-A baseline care plan had not been created for the resident’s PICC line.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0694

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 37)
During an interview on 4/16/19 at 10:31 A.M. LPN D said:
-PICC line dressing should be changed weekly and as needed.
-There should be physician’s orders [REDACTED].
-The nurse should change the dressing and sign off on the TAR when completed.
During an interview on 4/18/19 at 10:31 A.M. the Minimum Data Set (MDS a federally
mandated assessment tool completed by facility staff for care planning) Coordinator (also
an RN) said:
-The nurses were responsible for creating the baseline care plans.
-He/she would look over the care plan and add to the baseline care plan.
-The resident did not have a PICC line care plan.
-Weekly PICC line dressing changes needed to be completed weekly and as needed.
-The PICC line dressing should be dated when it was changed; and
-Only an RN can change the PICC line dressing.
During an interview on 4/19/19 at 10:57 A.M., the Director of Nursing (DON) and Corporate
Nurse B said:
-Baseline care plans were created on admission by the nurse or the nurse manager.
-The admitting nursing staff should print the baseline care plan off, make a copy, and
have it signed by the resident.
-The resident should have a baseline care plan for his/her PICC line; and
-PICC line dressing changes should be completed weekly, as needed, and documented on the
TAR.
A policy was requested but not received from the facility.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure a
[MEDICAL CONDITION] (a surgical incision in the neck to allow a direct airway) was kept
clean; to suction the [MEDICAL CONDITION] as needed and to document suctioning had been
done for one sampled resident (Resident #610) out of 23 sampled residents. The facility
census was 113 residents.
Record review of the facility’s policy titled Oxygen Use dated 3/2017, showed:
-The staff was to make sure nothing was blocking the resident’s air openings.
-The staff was to document the air flow (liters per minute).
-The staff was to document the PSI levels (Oxygen level) and
-The staff was to make sure the air openings were not blocked.
Record review of the facility’s policy titled [MEDICAL CONDITION] care: dated 8/2018,
showed:
-Daily [MEDICAL CONDITION] care included cleaning the stoma (the surgical hole in the
neck).
-Clearing the [MEDICAL CONDITION] of secretions.
-Changing the inner cannula (the inside tube).
-Replacing the neck tie.
-The following information should be recorded in the resident’s medical record:
–The date and time of [MEDICAL CONDITION] care.
–The resident’s response to treatment.
–The amount and consistency of secretion.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 38)
–Abnormal findings and
–The signature and title of the person recording the information.
1. Record review of Resident #610’s Face Sheet showed he/she had been admitted on [DATE]
with the following Diagnoses: [REDACTED].
-Vertebral fracture (bones in the spine crumble).
-Diabetes (a group of diseases that result in too much sugar in the blood) and
-The resident had a guardian.
Record review of the resident’s physician’s orders [REDACTED].
-[MEDICAL CONDITION] care every shift and as needed.
-Cleanse with normal saline.
-Pat dry.
-Apply a dry gauze.
-Monitor [MEDICAL CONDITION] site for bleeding and signs/symptoms of infection.
-Change [MEDICAL CONDITION] collar every day.
-[MEDICAL CONDITION] suctioning every shift and as needed.
-Change inner cannula every day and as needed.
-Check the resident’s oxygen saturation every 12 hours and as needed.
-Change the [MEDICAL CONDITION] every month.
-Keep an extra trachesotomy at bedside and
-Keep an ambu (a manual resuscitator) bag at bedside.
Record review of the Baseline Care Plan dated 4/09/19 showed:
-The resident was to have oxygen and
-The resident was to have his/her [MEDICAL CONDITION] suctioned.
The resident had not been in the facility long enough to have the Minimum Data Sheet (MDS
a federally mandated assessment tool completed by the facility for care planning) done.
Observation on 4/11/19 at 10:09 A.M. showed:
-The resident had his/her [MEDICAL CONDITION] mask on.
-The mask was dirty, the right side had a moderate amount (quarter size) of clear phlegm
in it.
-The mask was not centered over the [MEDICAL CONDITION] hole.
-Oxygen tubing from the humidifier was laying in a pool of clear liquid uncapped on the
bedside stand.
-The suction machine was at bedside.
-An ambu bag (a manual resuscitator) was at bedside.
-The resident is non verbal and
-Tube feeding (Glucerna 1.2) was running at 60 milliliter (ml)/hour
Record review on 4/11/19 at 11:52 A.M. of the Nurse’s Progress Notes showed:
-The resident had vomited dark brown coffee stuff as well as lots of mucus out of the
[MEDICAL CONDITION].
-The nurse practitioner was notified.
-Orders were received for a kidney, ureter, and bladder x-ray (KUB an X-ray study that
allows the organs of your urinary and gastrointestinal systems to be assessed).
-Orders were received for 2 view x ray.
-The resident’s respirations were 24 per minute.
-The resident’s oxygen saturation was between 89% to 91% with oxygen on.
-The nurse will continue to monitor and
-There was no documentation of the nurse suctioning the resident.
Observation on 4/11/19 at 12:24 P.M. showed the resident had thick white phlegm that had
run out of his/her mask and down the right arm of the resident about 12 inches long.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 39)
During an interview on 4/11/19 at 2:30 P.M. License Practical Nurse (LPN) A said:
-He/she has had [MEDICAL CONDITION] training.
-He/she tries to get into the resident’s room to check on him/her every two hours.
-He/she has been busy this shift.
-The [MEDICAL CONDITION] should be cleaned or changed if dirty and
-The [MEDICAL CONDITION] should be suctioned if there is a lot of phlegm.
Record review of the resident’s physician’s orders [REDACTED].
Record review on 4/11/19 at 5:14 P.M. of the Nurse’s Progress Notes showed:
-The resident had vomited what appeared as coffee ground emesis.
-The resident was struggling to breathe.
-The resident had lots of yellow mucus out of the [MEDICAL CONDITION].
-The resident oxygen saturation was at 88%.
-The resident was unresponsive (he/she was in a comatose state).
-The resident was sweaty.
-The resident was seen by the Nurse Practitioner (who was in the building).
-The resident was sent to the emergency room .
-The nurse notified the Director of Nursing (DON).
-The nurse notified the Guardian and
-There was no documentation of the nurse suctioning the resident.
During an interview on 4/18/19 at 12:30 P.M. the DON said:
-The nurses are to check on the residents every two hours.
-The nurses should suction a resident if needed and
-The nurse should chart if a resident needed to be suctioned.
During an interview on 4/19/19 at 11:00 A.M., LPN A said:
-He/she had charted after the incident.
-He/she had suctioned the resident often that day but may not have charted it and
-He/she was trying to get the resident to the hospital.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure
communication between the facility and the [MEDICAL TREATMENT] (a mechanical way to filter
the blood from an artery, remove waste, purifying it, adding vital substances and
returning it to a vein when the kidneys stop functioning) treatment center was maintained
and ongoing to ensure the continuum of care; to assess and accurately chart the assessment
of the resident’s [MEDICAL TREATMENT] shunt (an implanted tube to which an artery and vein
is attached to provide a larger than normal volume of blood flow for effective [MEDICAL
TREATMENT]) site for the presence of the bruit (a turbulent blood flow through the blood
vessel heard by auscultation (listening for the sound with a stethoscope) and thrill (a
vibration felt by palpation (feeling with the finger tips) in the blood vessel) for four
sampled residents (Residents #608, #101, #67, and #88) and did not remove a surgical
dressing for weeks after a peritoneal [MEDICAL TREATMENT] shunt was removed for one
sampled resident (Resident #608) out of 23 sampled residents. The facility census was 113
residents.
Record review of the facility’s Hemo (blood) [MEDICAL TREATMENT] care policy dated Oct.
2014 showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 40)
-Residents receiving [MEDICAL TREATMENT] treatments will be assessed and monitored to
ensure quality of life and well-being.
-On admission the resident’s site will be observed for function and signs and symptoms of
infection.
-The nurse will obtain orders for monitoring of the site, and interventions as
appropriate.
-A dietary assessment will be conducted to evaluate the need for fluid restriction/dietary
restrictions.
–Orders will be obtained as per recommendations.
-Intervention orders may include as per resident’s needs:
–[MEDICAL TREATMENT] Center, location, contact number and scheduled days.
–Access site/type.
–Diet as ordered from physician.
–Fluid restrictions as ordered by physician.
–Lab work as directed by [MEDICAL TREATMENT] and/or physician.
–Intake and output as needed.
–Medications as ordered.
–Diet counseling as needed.
–Observe shunt for signs and symptoms of infection/inflammation.
–Observe shunt for thrills and bruits every shift and report any abnormal findings to
Physician and/or [MEDICAL TREATMENT].
–No blood work or blood pressures in arm with shunt.
-A [MEDICAL TREATMENT] Care Plan will be initiated for interdisciplinary resident plan of
care.
-The facility will establish open communication with the [MEDICAL TREATMENT] Center via
the [MEDICAL TREATMENT] Communication Book:
–The nurse will establish pre [MEDICAL TREATMENT] vital signs (VS- blood pressure, pulse,
respirations and temperature).
–Advanced Directive status.
–Any pertinent facility communication.
-On return from the [MEDICAL TREATMENT] center the nurse will review the communication
returning from the [MEDICAL TREATMENT] center, indicating:
–Pre and post weights.
–Pre and post vital signs.
–Medications given at [MEDICAL TREATMENT].
–Labs drawn at [MEDICAL TREATMENT] and results if available.
–Resident’s tolerance to treatment.
-The nurse will evaluate the resident post [MEDICAL TREATMENT] for mental status, pain,
access site condition, and response to treatment.
-After evaluating the resident and reviewing the [MEDICAL TREATMENT] communication form,
the nurse will notify the Physician as indicated.
– All findings will be documented in the nursing progress note.
Record review of the undated facility’s [MEDICAL TREATMENT] Communication Log form showed:
-To be completed by the facility:
–Resident name, Primary Care Physician, date and time, the facility name, telephone and
fax number.
–Medications administered today.
–Vital signs (blood pressure, pulse, respirations, and temperature).
–Time of last meal, diet, and if need a meal or snack.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 41)
–Fluid restriction, if any, and the amount.
–Significant alerts.
–Nurses signature;
-To be completed by the [MEDICAL TREATMENT] center:
–The [MEDICAL TREATMENT] center name, telephone and fax numbers.
–Time of discharge form [MEDICAL TREATMENT].
–Pre and Post [MEDICAL TREATMENT] weights.
–Amount of fluid removed.
–Vital signs (blood pressure, pulse, respirations, and temperature) and date and time
obtained.
–Labs drawn and results.
–Medications/Treatments given at [MEDICAL TREATMENT].
–Patient tolerance to procedure.
–Follow-up orders.
–Appointments made.
–Problems/alerts.
–Nurses signature.
1. Record review of Resident #608’s Face sheet showed he/she was admitted on [DATE] with
the following Diagnoses: [REDACTED].
-Dependence on [MEDICAL TREATMENT].
Record review of the resident’s Minimum Data Sheet (MDS a federally mandated assessment
tool completed by the facility staff for care planning) dated 2/15/19 showed:
-The resident was alert and oriented.
-The resident needed extensive assistance with all activities of daily living; and
-The resident was able to make decisions independently.
Record review of the resident’s physician’s orders [REDACTED].
-The nurse was to check the fistula (a surgical connection between a vein and an artery
for [MEDICAL TREATMENT])every shift.
-The nurse was to check for the bruit and thrill and
-On 3/15/19 the peripherally inserted central catheter (PICC a long term tube used for
antibiotic and laboratory draws) line was to be discontinued.
Record review of the resident’s care plan dated 3/12/19 showed:
-The resident had [MEDICAL TREATMENT] on Monday, Wednesday, and Friday.
-The nurse was to document (the resident’s) condition.
-The nurse was to document any complications (from [MEDICAL TREATMENT]).
-The nurse was to monitor, document, and report to physician as needed any signs or
symptoms of infection.
-The nurse was to access the site for redness, swelling , warmth or drainage; and
-The nurse was to monitor, document, and report to the physician as needed any signs or
symptoms of bleeding, hemorrhage (profuse bleeding), bacteremia (bacteria in the blood),
or septic shock (a potentially fatal infection).
Record review of the resident’s physician’s discharge order summary dated 4/5/19 after
removal of peritoneal [MEDICAL TREATMENT] port (a treatment that uses the abdomen and a
solution to clean the blood) had the following instructions:
-Remove dressing in two days.
-May shower in two days.
-Let warm water run over incisions.
-Do not soak or scrub hard.
-Pat dry after shower; and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 42)
-Leave uncovered.
Observation and interview on 4/11/19 at 12:00 P.M. showed:
-The resident had two dressings on his/her front side.
-One was located on his/her stomach.
-The second one was on his/her right shoulder.
-The [MEDICAL TREATMENT] shunt was in his/her left arm; and
-The resident said he/she had told the staff to take off the dressings as they had been
there a long time (weeks).
Observation on 4/15/19 at 11:45 A.M. showed:
-The resident still had both dressings on his/her abdomen and shoulder; and
-The dressings had a date of 4/12/19 written on them.
During an interview on 4/15/19 at 12:01 P.M., Licensed Practical Nurse (LPN) A said:
-The resident did not have any dressings on.
-He/she checked it everyday.
-The resident had a peritoneal tube taken out a couple weeks ago.
-The resident had a PICC line removed a couple of days ago and
-He/she did not know how long the PICC line dressing should be on.
Record review of the resident’s (MONTH) bath sheets showed:
-He/she had taken only bed baths; and
-He/she had not taken any showers.
During an interview on 4/15/19 at 12:03 P.M. the Physician said:
-He/she would expect the staff to check the [MEDICAL TREATMENT] shunt.
-He/she would expect the staff to chart the assessment.
-The resident could have had a shower; and
-He/she would not have expected the staff to leave a dressing on more than a few days.
Record review of the resident’s Nurse’s Progress Notes dated 4/17/19 showed the dressings
were removed on 4/17/19 by the Wound Nurse.
During an interview on 4/19/19 at 11:04 A.M., the Director of Nursing (DON) said:
-He/she would expect the nurse to check the [MEDICAL TREATMENT] site; and
-He/she would expect it to be charted on the Medication Administration Record.(MAR).
At the time of exit the facility had not provided the resident’s MAR, Treatment
Administration Record (TAR) or any documentation of any assessment of the [MEDICAL
TREATMENT] shunt after having been requested.
2. Record review of Resident #101’s Admission Record showed he/she was admitted on [DATE]
and readmitted on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s Care Plan dated 3/19/19 showed he/she:
-Needed [MEDICAL TREATMENT] related to [MEDICAL CONDITION].
– Would have no signs/symptoms of complications from [MEDICAL TREATMENT] through the next
review date of 6/26/19 and
-Was at risk of altered hydration and nutrition status related to [MEDICAL CONDITION].
Record review of the resident’s Nursing Progress notes from 3/6/19 through 4/17/19 showed
no documentation of communication to or from the [MEDICAL TREATMENT] center.
Record review of the resident’s POS dated (MONTH) 2019 showed:
-[MEDICAL TREATMENT] on Monday, Wednesday and Friday with pick up at 3:00 P.M., and chair
time at 3:45 P.M.
-Check [MEDICAL TREATMENT] site right thigh for bruit and thrill every shift and notify
the physician with signs/symptoms of occlusion.
-Check [MEDICAL TREATMENT] site for bleeding and infection, notify the physician with any
signs/symptoms of infection immediately and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 43)
-No orange juice, banana, tomatoes, limit milk to eight ounces daily.
Record review of the resident’s [MEDICAL TREATMENT] book showed:
-A form that was to be filled out by the facility prior to going to [MEDICAL TREATMENT].
-Send the form with the resident for [MEDICAL TREATMENT] services to complete a portion.
-Incomplete [MEDICAL TREATMENT] Communication Form for the following dates only:
–On 3/22/19 the facility part only showed: left at 3:00 P.M., vital signs recorded and a
nurse’s signature.
–The [MEDICAL TREATMENT] part only showed: vital signs recorded and pre and post weight.
-No communication form for 3/25/19.
-On 3/27/19 the facility part only showed: left at 3:00 P.M., vital signs recorded.
-The [MEDICAL TREATMENT] part only showed: pre [MEDICAL TREATMENT] weight, and vital
signs.
-On 3/29/19 the facility part only showed: left at 3:00 P.M., vital signs recorded.
-The [MEDICAL TREATMENT] part only showed: vital signs recorded and pre and post weight.
-On 4/1/19 the facility part only showed: left at 2:00 P.M., vital signs recorded.
-The [MEDICAL TREATMENT] part was blank.
-The [MEDICAL TREATMENT] part only showed: vital signs recorded and pre and post weight.
-No communication form for 4/5/19.
-The [MEDICAL TREATMENT] part only showed: vital signs recorded and pre and post weight.
-The [MEDICAL TREATMENT] part showed: Resident left at 7:20 P.M., vital signs recorded,
pre and post weight, amount of fluid removed, and signed by a nurse.
-No communication form for 4/12/19.
-On 4/15/19 the facility part showed: no time that the resident left.
-The [MEDICAL TREATMENT] part was blank and
-No communication form for 4/17/19.
During an interview on 4/18/19 at 10:22 A.M. LPN F said:
-[MEDICAL TREATMENT] shunts are checked three times a day, once each shift.
-Shunts are checked by placing finger tips on the site and
-He/she could not describe what staff are feeling for with the finger tips.
During an interview on 4/18/19 at 1:37 P.M. LPN G said:
-Charting for checking the resident’s bruit and thrill is on the (MAR and
-He/she did not check the resident’s bruit and thrill due to it being signed off for the
7:00 A.M.-3:00 P.M. shift.
During an interview on 4/18/19 at 2:00 P.M. the resident said:
-No one in the facility checks his/her shunt.
-No one checked it that morning.
-His/her shunt is in his/her right thigh and
-To check the shunt he/she would have to drop his/her pants and no one has asked him/her
to do that.
During an interview on 4/19/19 at 8:20 A.M., LPN H said:
-The thrill is checked by palpating with finger tips for a vibration feel.
-The bruit is checked by listening with a stethoscope for a swish sound and
-He/she is waiting for the resident to return from the shower to check the thrill and
bruit.
3. Record review of Resident #67’s admission MDS dated [DATE] showed he/she was receiving
[MEDICAL TREATMENT].
Record review of the resident’s care plan dated 2/20/19 showed:
-The resident required [MEDICAL TREATMENT] related to [MEDICAL CONDITION].
-The goal was the resident would have no signs or symptoms of complications from [MEDICAL
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 44)
TREATMENT].
-Interventions included:
–Monitor, document and report any signs or symptoms of infection such as redness,
swelling, warmth or drainage of the access site.
–Monitor, document and report bleeding.
Record review of the resident’s (MONTH) 2019 POS showed physician’s orders
[REDACTED].>-For [MEDICAL TREATMENT] three times per week.
-To check the resident’s [MEDICAL TREATMENT] site in his/her left chest every shift for
bleeding and infection, notify the resident’s doctor with signs or symptoms of infection
and to call 911 with bleeding.
Record review of the resident’s (MONTH) 2019 MAR showed checking the [MEDICAL TREATMENT]
site was not on the MAR or TAR.
Observation and interview on 4/11/19 at 11:42 A.M. showed the resident was in his/her
room, and he/she said he/she goes to [MEDICAL TREATMENT] three times a week in the
afternoon.
Observation and interview on 4/18/19 at 1:24 P.M., showed the resident patted her left
chest area and said the facility staff do not check his/her [MEDICAL TREATMENT] site.
During an interview on 4/19/19 at 10:55 A.M., the DON said:
-He/she would expect that Physicians’ orders to check for a bruit and thrill be done each
shift by the nurse.
-He/she would expect that the MAR would be signed after checking the bruit and thrill.
-He/she would not expect the MAR to be signed that it was checked if it had not been
checked.
-The facility has several [MEDICAL TREATMENT] residents and would expect all nurses to
know how to check for the bruit and thrill and
-He/she would expect a nurse who does not know how to check for the bruit and thrill to
ask another nurse.
4. Record review of Resident #88’s face sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Dependence on [MEDICAL TREATMENT].
Record review of the resident’s care plan showed:
-Check the bruit and thrill every shift or as ordered; and
-Report signs and symptoms of occlusion or any other abnormalities to the physician.
Record review of the resident’s following POS’s showed:
-March 2019:
–Check the [MEDICAL TREATMENT] shunt every shift for Bruit/thrill.
–Check the [MEDICAL TREATMENT] shunt every shift of signs and symptoms infection and
bleeding.
–[MEDICAL TREATMENT] on Mon, Wed, and Fri.
-April 2019:
–[MEDICAL TREATMENT] Mon, Wed and Fri.
–Check the [MEDICAL TREATMENT] shunt every shift for Bruit/thrill.
–Check the [MEDICAL TREATMENT] shunt every shift of signs and symptoms infection and
bleeding.
–The shunt must be checked every shift for bleeding or any signs of infection; and
–Notify the physician for signs/symptoms and bleeding and to call 911 if bleeding.
Record review of the MAR/TAR showed the following documentation:
-Check the [MEDICAL TREATMENT] shunt every shift for Bruit/thrill:
–August (YEAR), 44 times out of 93 opportunities, resulted in 47 percent (%)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 45)
documentation rate.
–January 2019, unable to review, requested information three times.
–February 2019, unable to review, requested information three times.
–March 2019, zero times out of 90 opportunities, resulted in a 0% documentation rate.
–April 2019, zero times out of 90 opportunities, resulted in a 0 %documentation rate.
-Check the [MEDICAL TREATMENT] shunt every shift of signs and symptoms infection and
bleeding:
–August (YEAR), 44 times out of 93 opportunities, resulted in 47% documentation rate.
–January 2019, unable to review, requested information three times.
–February 2019, unable to review, requested information three times.
–March 2019, zero times out of 90 opportunities, resulted in a 0% documentation rate; and
–April 2019, zero times out of 90 opportunities, resulted in a 0% documentation rate.
Record review of the [MEDICAL TREATMENT] Communication Book showed no communication forms
for this resident from 7/25/18 through 4/15/19.
During an interview on 4/16/19 at 11:09 A.M., LPN C said:
-Every shift checked and documented, on the resident’s MAR/TAR, the thrill/bruit and signs
and symptoms of infection and bleeding.
-All [MEDICAL TREATMENT] residents have a [MEDICAL TREATMENT] Communication Book; and
-The nurse was to fill out the top portion of the Communication Form before [MEDICAL
TREATMENT].
During an interview on 4/18/19 at 10:22, the resident said:
-He/she did not like when the nurses took his/her [MEDICAL TREATMENT] Communication Book.
-He/she liked to keep his/her [MEDICAL TREATMENT] Communication Book in his/her
wheelchair; and
-The nursing staff did not change his/her [MEDICAL TREATMENT] dressing.
During an interview on 4/18/19 at 11:10 A.M., the DON said:
-He/she expected the nursing staff to fill out the top portion of the Communication Form
every time before the resident went to [MEDICAL TREATMENT].
-He/she expected the nurses to assess the site as ordered and document on the nurses
MAR’s.
-Nurses did not change the dressing covering the [MEDICAL TREATMENT] site.
–They have no order to change the dressing; and
–The facility has communicated this with the [MEDICAL TREATMENT] center.
During an interview on 4/18/19 at 11:10 A.M. the Regional Corporate Nurse, Registered
Nurse (RN) B said:
-Nurses can take the [MEDICAL TREATMENT] dressing off after 24 hours at the facility and
-He/she would get it clarified.
MO 230

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Observe each nurse aide’s job performance and give regular training.

Based on interview and record review, the facility failed to provide the 12 hours of
Dementia training for the staff as required. There are Dementia residents living in the
facility. The facility census was 113 residents.
1. Record review of the facility’s employees’ educational sheets showed:
-The education did not include any Dementia training.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 46)
-Three employees were reviewed who have been employed at this facility for at least 12
consecutive months:
–The Director of Nursing (DON) was the only Registered nurse who had been employed at
this facility for more than 12 months.
–Licensed Practical Nurse (LPN) D.
–LPN C.
–Certified Nursing Assistant (CNA) I.
During an interview on 4/19/19 at 11:00 A.M. LPN A said:
-He/she has not had any Dementia training at this facility and
-There were residents who had Dementia living here.
During an interview on 4/19/19 at 11:04 A.M. the DON said:
-He/ she had been at the facility more than a year.
-He/she had not done any Dementia education.
-The staff had not done any Dementia training and
-The facility had residents with Dementia.
A facility policy was requested but no facility policy was provided at the time of exit.

F 0740

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident must receive and the facility must provide necessary behavioral
health care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to meet the
behavioral needs for one sampled resident (Resident #102) out of 23 sampled residents by
not monitoring mood and behaviors for a resident with a long psychiatric history and a
psychiatric in-patient hospital stay for potential self-harm during his/her course of stay
at the facility; and to update the care plan to include his/her suicidal ideation and
monitoring of these potential behaviors. The facility census was 113 residents.
Record review of the facilities Behavioral Management policy dated 2/2019 showed:
-It is the policy of this facility to provide an interdisciplinary approach for the care
of the residents who exhibit problem behavioral symptoms which could lead to negative
consequences for themselves or others.
-Behavioral symptoms and approaches shall be placed in the residents-specific plan of care
and communicated to the care staff and other departments, as appropriate; and
-Residents with a history of behavior problems shall be properly monitored.
1. Record review of Resident #102’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Major [MEDICAL CONDITION] (a mood disorder that causes a persistent feeling of sadness
and loss of interest).
-Personal history of self-harm.
-Alcohol dependence, in remission; and
-Cocaine abuse.
Record review of the resident’s physician’s orders [REDACTED].
-Trazadone 100 milligrams (mg) daily for depression.
-On 3/16/19:
–[MEDICATION NAME] 0.5 mg twice a day for anxiety (a psychiatric disorder causing
feelings of persistent anxiety); and
–[MEDICATION NAME] 40 mg daily (for depression).

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0740

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 47)
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by facility staff for care planning) dated
3/18/19 showed he/she:
-Was cognitively intact; and
-Did not have behaviors.
Record review of the residents physician progress notes [REDACTED].
-The resident had racing thoughts.
-The resident was currently admitted to the long-term care unit.
-He/she suffers from multiple medical problems to include recent history of [MEDICAL
CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability of the
lungs to perform ventilation) exacerbation as well as positive for influenza (flu).
-He/she carried an extensive psychiatric history to include having been treated in the
past for [MEDICAL CONDITION] disorder, polysubstance abuse to include cocaine and
[MEDICATION NAME], as well as anxiety and depression.
-While at the hospital, he/she was seen by psychiatry, and was started on [MEDICATION
NAME] and [MEDICATION NAME] (to treat his/her mental illness) at bedtime.
-While here at the facility his/her [MEDICATION NAME] has been increased to 40 mg daily.
-He/she was also started on [MEDICATION NAME] at 0.5 mg twice a day for increased anxiety.
-Assessment: (of diagnoses);
–[MEDICAL CONDITION] disorder-manic phase.
–Anxiety disorder; and
–Depression.
Record review of the resident’s Care Plan dated 3/24/19 showed he/she:
-Used medications to treat anxiety, bi-polar disorder, and depression; and
-Needed the staff to monitor for the side effects of the medication and report to the
resident’s physician any side effects.
Record review of the residents Nursing Progress Note dated 4/1/19 showed:
-The resident went to his/her appointment at a psychiatrist office.
-The psychiatrists’ office called and stated there were some concerns about him/her
stating he/she wanted to harm himself/herself and they felt it best if he/she be seen in
the emergency room prior to returning to the facility; and
-Nursing agreed that would fine.
Record review of the resident’s Nursing Progress Note date 4/8/19 showed:
-The resident was readmitted to the facility from the hospital; and
-The resident was readmitted for long-term care.
Record review of the resident’s hospital medical record dated 4/8/19 showed:
-The resident was discharged to the nursing home in stable condition.
-The resident was seen for medical conditions and for psychiatric conditions.
-Aftercare recommendations were outpatient treatment.
-The resident had the following Diagnoses: [REDACTED].
–Anxiety disorder.
–Post-Traumatic Stress Disorder ([MEDICAL CONDITION]-a mental health condition that’s
triggered by a terrifying event – either experiencing it or witnessing it. Symptoms may
include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts
about the event).
-Alcohol use disorder, in remission.
-[MEDICATION NAME] use disorder, in remission; and
-Cocaine use disorder, in remission.
Record review of the resident’s 4/2019 POS showed the following physician ordered
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0740

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 48)
medications: [REDACTED]
-[MEDICATION NAME] 300 mg at bedtime daily for a mood stabilizer.
-[MEDICATION NAME] 60 mg tablet daily at bedtime for mood.
-[MEDICATION NAME] 25 mg tablet every four hours as needed for anxiety.
-[MEDICATION NAME] 0.25 three times per day for anxiety; and
-[MEDICATION NAME] 10 mg tablet twice daily for anxiety.
Record review of the resident’s physician’s History and Physical Progress Note dated
4/10/19 showed:
-The resident was readmitted to the facility and had a history of [REDACTED].
-The resident had recently gone to an outpatient psychiatric appointment, where he/she
expressed suicidal ideation and was transferred to inpatient psychiatric services; and
-He/she was readmitted today, and stated he/she was not having any suicidal or homicidal
ideation, however he/she was having racing thoughts which are better than previous however
he/she admitted to feeling somewhat stable.
Record review of the resident’s medical record on 4/14/19 showed there was no staff
documentation or monitoring of the resident’s [MEDICAL CONDITION].
During an interview on 4/14/19 at 12:10 P.M., the resident said:
-He/she had no issues with [MEDICAL CONDITION] since his/her in-patient psychiatric
hospital stay.
-He/she was his/her own responsible party; and
-His/her medications were adjusted.
During an interview on 4/15/19 at 10:21 A.M. Certified Medication Technician (CMT) C said:
-He/she did not document on resident behaviors.
-This was the nurses’ responsibility.
-The documentation for behaviors should be on the Nurses Medication Administration Record
[REDACTED]
-The resident did not have any behaviors or [MEDICAL CONDITION] that he/she was aware of.
-The resident, in the past, was upset related to his/her medications; and
-The resident’s medications have all changed after his/her in-patient psychiatric hospital
stay.
Record review of the resident’s Care Plan revised on 4/16/19 showed he/she:
-Was unable to go on therapeutic leave at this time due to unstable mental status and
[MEDICAL CONDITION]; and
-Would have a consult with the facility’s psychiatric physician on his/her next visit.
Observation on 4/16/19 at 7:32 A.M. showed the resident was at the nurses station dressed
and groomed with his/her significant other talking with the nurse.
During an interview on 4/18/19 at 10:31 A.M. the MDS Coordinator said:
-He/she was responsible for updating the care plans.
-Sometimes, the nurses would update the care plans; and
-He/she had created the care plan for the resident but did not add a behavioral care plan.
During an interview on 4/18/19 at 11:04 A.M. Licensed Practical Nurse (LPN) A said:
-The nurses were responsible for ensuring the resident’s behaviors of [MEDICAL CONDITION]
were monitored.
-Upon admit and re-admission, the admitting nurse should have created a behavioral flow
sheet on the resident’s MAR indicated [REDACTED].
-The nurses were responsible for informing direct care staff to report any behavioral
changes to the nurse; and
-The care plan for the resident’s [MEDICAL CONDITION] should have been added upon
re-admission to the facility by the nurse.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0740

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 49)
During an interview on 4/19/19 at 10:57 A.M., the Director of Nursing (DON) and Corporate
Nurse B said:
-He/she expected the nurses to monitor the resident for seven days upon re-admission.
-The nurses should monitor the resident for self-harm and document the monitoring in the
nurses notes; and
-He/she expected the resident’s potential for self-harm to be care planned and this should
have been updated on the care plan by the MDS Coordinator.

F 0745

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide medically-related social services to help each resident achieve the highest
possible quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure the resident was
provided assistance with identifying community placement options and completing the
application process or in making arrangements for home care services or transfer to
another facility, according to the resident’s needs, to ensure one sampled resident
(Resident #158) out of 23 sampled residents had a safe and appropriate discharge. The
facility census was 113 residents.
1. Record review of Resident #158’s undated Face Sheet showed he/she was admitted to the
facility on [DATE] and was his/her own responsible party. A family member was listed as a
primary contact. The resident had [DIAGNOSES REDACTED].>-Stimulant Abuse (a condition
in which the use of one or more stimulant substances (drugs that raise the levels of
physiological or nervous activity in the body) leads to significant impairment or
physical, mental or social distress).
-[MEDICAL CONDITION] Disorder (a disorder associated with mood swings ranging from
depressive lows to manic (exaggerated excitement) highs); and
-Muscle Weakness.
Record review of the resident’s Baseline Care Plan, dated 12/18/18 showed:
-The resident’s initial discharge goals were to transfer to a Residential Care Facility
(RCF – a facility that provides basic supervision and personal care assistance with
activities such as hygiene and dressing); and
-The resident was receiving Rehabilitation Therapy (services that help a person regain
cognitive (mental) and/or physical abilities that have been lost or impaired as a result
of disease, lack of use or injury).
Record review of the resident’s Social Services note, dated 12/25/18 showed:
-The resident was cognitively intact.
-The resident’s Social Services Assessment had been completed; and
-The note contained no further information about the resident.
Record review of the resident’s Admission Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning), dated 12/25/18,
showed:
-The resident was cognitively intact; and
-The resident was receiving Therapy services.
Record review of the resident’s Plans to Discharge into the Community Care Plan, dated
1/3/19 showed:
-The resident would be involved in discharge planning and assisted with applications for
community resources.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0745

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 50)
-Appropriate referrals would be made as needed.
-Support and counseling would be provided related to discharge concerns; and
-The Social Worker would meet with the resident to identify needs for discharge.
Record review of the resident’s Substance Use, Jeopardizing Health and Safety Care Plan,
dated 3/20/19 showed:
-The resident was to have therapeutic leave and go to medical appointments with an escort
due to the unsafe use of substances while out of the facility; and
-The resident was to notify staff when he/she left from and returned to the facility.
Record review of the resident’s Nurses’ Notes, dated 3/26/19 at 12:06 A.M. showed:
-Earlier in the shift on 3/25/19 the resident voiced a desire to leave the facility and
was encouraged to go out on pass with a responsible party and wait until he/she had a
planned discharge.
-Around 10:15 P.M. the resident informed the nurse he/she was leaving the facility Against
Medical Advice (AMA).
-The resident was again encouraged to go out on pass with a responsible party instead of
leaving the facility AMA.
-The resident insisted he/she was leaving the facility AMA.
-The Nurse Practitioner and Director of Nursing (DON) were notified; and
-The resident signed that he/she was leaving the facility AMA at 10:30 P.M., then
contacted a cab and left the facility shortly thereafter. The note did not show if the
resident mentioned where he/she was going.
Record review of the resident’s progress notes showed no documentation of the family
member listed as the resident’s primary contact was notified that the resident left the
facility AMA.
Record review showed no Social Services notes or assessments following the Social Services
note of 12/25/18 and these were requested on 4/16/19, 4/18/19 and 4/19/19.
During an interview on 4/18/19 at 11:43 A.M. the Social Worker (SW) said:
-When he/she first started working at the facility in late February, 2019 the resident
said he/she wanted to be discharged and wanted to stay with a family member.
-He/she contacted the family member who said the resident living with him/her was not an
option. The SW discussed this situation with the resident.
-He/she never discussed the resident’s discharge again with the resident.
-The resident had no clearly defined discharge plan and no social services progress notes.
-Discharge planning steps were not started for the resident; and
-The resident left AMA on 3/25/19 with no arrangements for an appropriately planned
discharge to the community.
During an interview on 4/19/19 at 10:58 A.M. the Director of Nursing (DON) said:
-When a resident is admitted to the facility for Skilled Therapy the resident’s care plan
goals, to include discharge goals begins at the time of admission.
-The SW should communicate potential resident discharges to other facility staff in
morning meetings and during weekly meetings. Additionally the SW can send e-mails of
potential resident discharges.
-Social Services should meet with the resident upon admission and approximately weekly if
the resident is receiving therapy services and may need to meet more often if the resident
is close to being discharged .
-Social Services notes should show what the social worker has done regarding the
resident’s discharge plans or other long term plans for the resident.
-The SW should communicate with the physician about the resident’s discharge plans; and
-Appropriate referrals and services should be arranged before discharge whenever possible.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0745

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide pharmaceutical services to meet the needs of each resident and employ or obtain
the services of a licensed pharmacist.

Based on interview and record review, the facility failed to ensure the narcotics were
counted every shift with accompanying signatures to verify the correct narcotic count, and
to ensure signatures were from an on-coming and off-going staff member. The facility
census was 113 residents
Record review of the Controlled Substances Policy, with a revised date of 2/11/19 showed:
-Nursing staff must count controlled medications at the end of each shift.
-The nurse coming on duty and the nurse going off duty must make the count together; and
-The staff must document and report any discrepancies to the Director of Nursing (DON).
1. Record review of the Eight Hour Verification of Controlled Substance Card Count for
(MONTH) 2019 showed:
-Medication cart one had:
–43 missing signatures out of 186 opportunities, resulting in a 23 percent (%) missing
rate.
–8 times both on-coming and off-going signatures were the same, resulting in a 4%
duplication rate.
-Medication cart two had:
–106 missing signatures out of 186 opportunities, resulting in a 57% missing rate.
–1 time both on-coming and off-going signatures were the same, resulting in a 0.005%
duplication rate.
-Medication cart three had:
–38 missing signatures out of 186 opportunities, resulting in a 20% missing rate; and
–3 times both on-coming and off-going signatures were the same, resulting in a 2%
duplication rate.
During an interview on 4/11/19 at 9:37 A.M., Certified Medication Technician (CMT) A said:
-On-coming and off-going staff count narcotics at the change of shift.
-They would sign the Eight Hour Verification of Controlled Substance Card Count sheet when
finished; and
-Discrepancies were reported to the DON.
During an interview on 4/19/19 at 10:57 A.M. the Director of Nursing (DON) said he/she
expected:
-Narcotics to be signed out immediately after given.
-To see narcotic counts done at every shift change with signatures; and
-Discrepancies to be reported to him/her.
At the time of exit, the facility had still not provided (MONTH) 2019 and (MONTH) 2019
Eight Hour Verification Of Controlled Substance Card Count sheets, after being requested.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 52)
Based on observation, interview and record review, the facility failed to ensure
medications and medical supplies were disposed of prior to the expiration date and removed
from the delivery system; to ensure open dates were on opened multi-dose medications; to
ensure medications were stored per pharmacy directions; to ensure the medication cart did
not contain unidentified loose pills in the cart; to ensure all medications remained in
the original container; to ensure staffs personal belongings were not stored on the
medication carts; and to ensure cleanliness of the medication cart. The facility census
was 113 residents.
Record review of the United States Food and Drug Administration (U.S. FDA) began requiring
an expiration date on prescription and over the counter medications in 1979 stating The
medicine expiration date is a critical part of deciding if the product is safe to use and
will work as intended.
Record review of the facility’s undated Medication Storage Policy showed:
-Expired, discontinued and/or contaminated medications will be removed from the medication
storage areas and disposed of in accordance with facility policy.
-Medications will be stored at the appropriate temperature in accordance with the pharmacy
and/or manufacturer labeling.
-Medications requiring refrigeration will be stored in a refrigerator that is maintained
between two to eight degrees Celsius (C) 36-46 degrees Fahrenheit (F); and
-Medications will be stored in the original, labeled containers received from the
pharmacy.
1. Observation on 4/11/19 at 9:06 A.M., the following medications and medical supplies had
expired:
-Nurse’s medication cart for the 100, 300 and odd side of the 500 halls:
–One vial of [MEDICATION NAME] (medicine to reduce mucus/secretion production) 0.5% oral
drops, expired 3/25/19.
–Two vials of [MEDICATION NAME] ([MEDICATION NAME]) [MEDICATION NAME] (medicine to treat
mental/mood disorders) Injectable 5 milligram (mg-unit of measure)/milliliter (ml-unit of
measure), vials showed expired 12/2018.
–Nine 60XLTIN (extended length [MEDICAL CONDITION] (surgical opening into the wind pipe
into which a tube is inserted to allow passage of air and removal of secretions) tube with
disposable inner cannula) cannulas expired (MONTH) 2019.
-Main medication room:
–Intravenous (IV-a device to administer solutions/medications through a vein) start kits
expired:
—One expired 1/2018.
—One expired 6/2018.
—27 expired 12/2018.
–Starswab (a self-contained, sterile, ready-to-use culture transport system):
—Two expired on 6/28/2017.
—Three expired on 3/7/2019.
–Sterile gloves:
—Two expired on 6/2017; and
—One expired on 12/2017.
Observation on 4/11/19 at 9:06 A.M. of,the nurse’s medication cart for the 100, 300 halls
and the even side of the 500 hall the following had no open dates:
-One bottle of Tylenol liquid 160 mg/5 ml; and
-One bottle of Ultra Tuss (cough suppressant).
Observation on 4/11/19 at 9:37 A.M., of the Certified Medication Technician’s (CMT) cart
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 53)
for the 400 hall and the odd side of 300 and 500 halls the [MEDICATION NAME] liquid 2
mg/ml bottle had no opening date.
Observation on 4/15/19 at 6:43 A.M., of the nurse’s medication cart for the 400 hall and
the odd side of the 500 hall the following had no open dates:
-One bottle of Levetiracetam (medicine to treat [MEDICAL CONDITION]) liquid 100 mg/ml.
-One bottle of Generic Tylenol liquid 160 mg/5 ml.
-One bottle of [MEDICATION NAME] (Schedule II controlled substance to treat pain)
concentrate liquid 100 mg/5 ml.
-One bottle of [MEDICATION NAME] (Schedule II controlled substance is among the most
powerful medication for relief of severe pain) liquid 100 mg/5 ml x2 bottles; and
-One bottle of [MEDICATION NAME] (medication to treat severe pain or narcotic addiction)
10 mg/ml.
During an interview on 4/11/19 at 9:06 A.M. Licensed Practical Nurse (LPN) A said:
-There was no set time to check the carts; and
-We do it when we have time.
Observation on 4/11/19 at 9:06 A.M. the following items were not refrigerated:
-Nurse’s medication cart for the 100, 300 and odd side of the 500 halls:
–Two vials of Humalog (Insulin) vial unopened, clearly labeled with a refrigerate label
from the pharmacy.
-CMT’s medication cart for the 400 hall and the odd side of 300 and 500 halls:
–Four vials of [MEDICATION NAME] (a medication to treat high pressure inside the eye)
0.005% eye drops, clearly labeled with a refrigerate label from the pharmacy.
During an interview on 4/11/19 at 9:06 A.M. LPN A said he/she was unsure if the
medications needed to be refrigerated.
During an interview on 4/11/19 at 9:37 A.M. CMT A said:
-He/she goes through the cart daily to check for expired items; and
-The pharmacy goes through the cart once a week to check for expired medications.
During an interview on 4/11/19 at 9:37 A.M. CMT A said he/she was unsure if the
medications needed to be refrigerated.
Observation on 4/11/19 at 9:06 A.M., of the nurse medication cart for the 100, 300 and odd
side of the 500 hall, showed two unidentified pills found loose in the top drawer.
During an interview on 4/11/19 at 9:06 A.M. LPN A said
-They should not be loose in the cart; and
-They probably just fell out and no one picked them up.
Observation on 4/11/19 at 9:06 A.M. showed the following personal items in medication
carts:
-The nurse’s medication cart for the 100, 300 and odd side of the 500 hall:
–LPN A removed a personal phone from the top drawer of the medication cart; and
–LPN A removed personal keys out of top drawer of medication cart.
During an interview on 4/11/19 at 9:06 A.M. LPN A said his/her phone and keys should not
be in the medication cart.
Observation on 4/15/19 at 6:43 A.M. of the nurse’s medication cart for the 400 and odd
side of the 500 hall in the narcotic box showed:
-One plastic bag with:
–A bottle of [MEDICATION NAME] 5 mg IR (Immediate Release) with one tablet in the bottle.
–Four sealed medication crushing bags (heavy plastic) each with 10 tablets in them and
—No identification marks on bag (of name, dose, and date).
During an interview on 4/15/19 at 6:43 A.M. LPN B said he/she:
-Did not know why there were medication crushing bags with medications in them.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 54)
-Did not think that was right.
-Guessed, because would be easier to count and
-Did not like it and was going to talk with the DON.
Observation on 4/15/19 at 6:43 A.M. of the nurse’s medication cart for the 400 and odd
side of the 500 hall showed LPN B removed personal cookies from within the top drawer.
During an interview on 4/15/19 at 6:43 A.M. LPN B said, he/she knew his/her bag of cookies
shouldn’t be in the medication cart.
During an interview on 4/19/19 at 10:57 A.M. the DON said:
-He/she would expect:
–Medication carts to be checked for expired items, both medications and medical supplies
every night by the night shift;
–Medication rooms to be checked for expired items every night by the night shift.
–If unopened, Humalog to be refrigerated.
–If opened Humalog can go into the cart for 28 days.
–[MEDICATION NAME] to be kept in the refrigerator.
–Medications to stay in the original bottle.
–All spills cleaned up nightly.
-He/she would not expect:
–To see expired supplies/medications on the medication carts.
–To see expired supplies/medications in the medication rooms.
–To see unopened vials of Humalog Insulin in the medication cart.
–To see loose pills in the medication carts.
–To see medications removed from original bottle and re-packaged for ease of counting.
–To see staff’s personal cell phones/car keys in the medication carts; and
–To see employee’s personal food in the medication cart.

F 0790

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide routine and 24-hour emergency dental care for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide dental
services for one sampled resident (Resident #62) out of 23 sampled residents, who had
teeth in poor repair. The facility census was 113 residents.
Record review of the facility Dental Services policy revised 11/2017 showed routine and
emergency dental services were available to meet the resident’s oral health services in
accordance with the resident’s assessments and plan of care.
1. Record review of Resident #62’s Face Sheet showed the resident was admitted to the
facility on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s significant change Minimum Data Set (MDS-a federally
mandated assessment tool required to be completed by facility staff for care planning)
dated 5/21/18 showed the resident:
-Was cognitively intact; and
-Had no dental concerns.
Record review of the resident’s Care Plan revised on 11/8/18 showed the resident needed
the assistance of one staff member for Activities of Daily Living (ADLS-dressing, bathing,
and grooming).
During an observation and interview on 4/11/19 at 11:11 A.M., the resident said:
-He/she had broken teeth and missing teeth.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0790

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 55)
-He/she had not received dental services since he/she was admitted here.
-He/she had asked a few times to different staff but had never had a dental visit.
-Observation showed the resident had a few missing teeth and had a front, left tooth
broken off that was blackened; and
-He/she did experience mouth pain at times related to the condition of his/her teeth.
During an interview on 4/16/19 at 9:14 A.M., the Social Services Director (SSD) said:
-He/she was assisting the residents with dental services.
-It was not brought to his/her attention the resident had teeth in poor repair; and
-The resident had not been seen by the dentist recently and was not on the list to see the
dentist.
During an interview on 4/16/19 at 11:47 A.M. Certified Nursing Assistant (CNA) A said:
-He/she worked with the resident on a daily basis.
-He/she was unaware the resident’s teeth were in poor repair.
-He/she thought the resident was being seen by a dentist; and
-Observation showed the resident opened his/her mouth and he/she had a left tooth broken
off that was blackened.
During an interview on 4/18/19 at 10:07 A.M. CNA F said:
-He/she was not aware the resident’s teeth were in poor repair; and
-The resident usually brushed his/her own teeth.
During an interview on 4/18/19 at 10:31 A.M. the MDS Coordinator (also a Registered
Nurse-RN) said:
-The resident’s teeth were in poor repair and this was discussed in a care plan meeting a
while ago; and
-He/she thought the SSD had set up dental services after the care plan meeting was held.
During an interview on 4/18/19 at 11:04 A.M., Licensed Practical Nurse (LPN) A said:
-He/she expected the CNAs to notify the nurse if a resident had teeth in poor repair; and
-He/she was unsure who set up dental appointments for the residents, maybe Social
Services.
During an interview on 4/19/19 at 10:57 A.M., the Director of Nursing (DON) and Corporate
Nurse B said:
-If a resident had teeth in poor repair, he/she expected the staff to make a note in the
residents’ medical record.
-All staff were responsible for identifying teeth in poor repair including the CNAs,
nurses, and MDS Coordinator; and
-He/she expected the staff to notify the Social Services Director so an appointment can be
made for the resident to see the dentist.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation and interview, the facility failed to refrigerate an open sauce jug;
to maintain clean floors in the walk-in refrigerator and freezer; and to keep the range
hood’s fire suppression nozzle pipes above the stove free from excessive grease build-up.
These practices potentially affected all residents who ate food from the kitchen. The
skilled nursing facility census was 113 residents with a licensed capacity for 180.
1. Observations during the kitchen inspection on 4/11/19 between 8:44 A.M. and 1:04 P.M.,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 56)
showed the following:
– An opened 1 gallon jug of teriyaki sauce with approximately 1 ? cups left in it that was
being stored on a shelf by the ice machine read refrigerate after opening on its label.
– The walk-in refrigerator and freezer floors had trash and food debris under the storage
racks, and
– The range hood’s fire suppression nozzle pipes above the stove had an excessive build-up
of grease to the touch.
During an interview on 4/16/19 at 10:43 A.M. the Dietary Manager said the following:
– He/she would expect any foods that said to refrigerate after opening would be.
– The dietary staff are to clean the walk-in floors nightly and deep clean monthly, but it
had not been done for a while, and
– He/she did not know if the company hired to clean the range hood did a good job or not,
though the nozzle pipes should be part of that process to prevent food contamination.

F 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have a policy regarding use and storage of foods brought to residents by family and
other visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review, the facility failed to educate all staff as to the
existence, whereabouts, and contents of a written, on-site policy regarding the
acceptance, usage, and storage of foods brought into the facility for residents by family
and other visitors, to ensure the food’s safe and sanitary handling and consumption. This
deficient practice had the potential to affect all residents who ate food brought in by
visitors. The facility census was 113 residents with a licensed capacity of 180 residents.
Record review on 4/11/19 at 10:49 A.M. of the policies provided by the Dietary Manager
from the Dietary Manual binder showed three separate pages that were entitled Food Brought
in from Outside the Community with four procedure points, Guidelines for Families Bringing
Food in from Home with five points on food safety, and POLICY: Food From Outside Food
Sources with six points of ‘Policy Interpretation and Implementation, respectively, that
had no facility specific information and were obtained online from the Innovation Services
Diet Manual.
Record review of the policy entitled Food from Outside (Brought by Families) provided by
the Administrator showed a different generic document with seventeen points of Policy
Interpretation and Implementation obtained online that had the corporate logo added to the
upper right corner, but had not been individualized to the facility.
1. During an interview on 4/12/19 at 2:31 P.M., Licensed Practical Nurse (LPN) A said if
food is brought in from the outside:
– It has to match the resident’s diet.
– They confirm that the resident can feed him/herself.
– It’s put in the medication room refrigerator, and
– He/she did not believe the procedure was written down anywhere, they just learned of it
by word of mouth early on.
During an interview on 4/16/19 at 9:17 A.M., LPN D said if food is brought in from the
outside:
– The container is labeled with the resident’s name and dated.
– They will give it to the resident upon request.
– If not eaten, the food is only kept for three days.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 57)
– He/she thought he/she had read the procedure somewhere in the last eight years and
he/she just remembered what it said, and
– He/she did not know where the procedure might be located.
During an interview on 4/16/19 at 9:25 A.M., Certified Nursing Assistant (CNA) G said if
food is brought in from the outside:
– They would check the resident’s diet first.
– Label the container.
– Tell the charge nurse.
– Put it in the appropriate refrigerator, and
– He/she thought the procedure was written down somewhere because he/she had seen it in
the last [AGE] years, but he/she couldn’t say exactly when.
During an interview on 4/16/19 at 10:43 A.M., the Dietary Manager said the direct care
staff should all know the outside food policy and where it is, but it is not in-serviced
often enough for their re-education, and it should probably be in the resident’s admission
packets, too.
During an interview on 4/16/19 at 11:41 A.M., the Administrator said they would expect the
direct care staff to know where the outside food policy is and what it contains.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview, the facility failed to establish and
maintain a comprehensive infection prevention and control program designed to help prevent
the development and transmission of water borne pathogens (a bacterium, virus, or other
microorganism that can cause disease) and to provide documented assessments for such an
outbreak. This deficient practice had the potential to affect all residents, visitors, and
staff who reside in, visit, use, or work in the facility; and to ensure [MEDICAL
CONDITION] (TB-a lung infection caused by a bacterium) testing was completed for one
sampled resident (Resident #309); to maintain sterile procedure while doing [MEDICAL
CONDITION] (surgical opening into the wind pipe into which a tube is inserted to allow
passage of air and removal of secretions) care (Trach care) for one sampled resident
(Resident #40); to ensure proper hand washing and/or hand sanitizing was completed with
glove changing [MEDICAL CONDITION] for one sampled resident (Resident #93), and to keep
oxygen tubing clean for one sampled resident (Resident #610) out of 23 sampled residents.
The facility census was 113 residents with a licensed capacity for 180.
Record review of the facility’s policy [MEDICAL CONDITION] Screening for Resident’s
updated on 11/2018 showed:
-All residents would receive a two-step TB test upon admission; and
-The policy did not direct the staff what to do if the resident refused the two-step TST
upon admission.
Record review of the facility’s Infection Control Program Policy last updated 2-2018
showed:
-Handwashing continues to be the primary means of preventing the transmission of
infection.
-The staff is educated on proper handwashing technique, when to wash hands and monitored
for compliance.
-Staff involved in direct resident care wear intact disposable gloves that are changed

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 58)
after each use.
Record review of the facility’s Handwashing/Hand Hygiene Policy last revised 1-2017
showed:
-Wash hands with soap and water or an alcohol-based hand rub.
–Before and after direct contact with residents.
–Before and after handling an invasive device.
–Before applying non-sterile and sterile gloves.
–After contact with objects (e.g., medical equipment) in the immediate vicinity of the
resident.
–After removing gloves.
Record review of the facility’s policy titled Oxygen Use dated 03/2017, showed:
-The staff was to make sure nothing was blocking the resident’s air openings; and
-Tubing change was done weekly and as needed.
Record review of the facility’s policy titled [MEDICAL CONDITION] (trach a surgical
incision in the neck to allow a direct airway) Care, dated 08/2018, showed:
-[MEDICAL CONDITION] included cleaning the stoma (the surgical hole in the neck); and
-Trach care is done to prevent infection.
1. Record review on 4/15/19 at 12:45 P.M., of the facility’s Emergency Plan (EP) program
entitled Disaster Plan, which was obtained from the central nurse’s station, failed to
show the following:
– A facility risk assessment or water management program that considers the ASHRAE
industry standard.
– A CDC toolkit including control measures such as physical controls, temperature
management, disinfectant level control, visual inspections, and environmental testing for
pathogens.
– A schematic or diagram of the facility’s water system, and
– An infection prevention program or plan to deal with outbreaks of Legionella and/or
other water borne pathogens.
During an interview on 4/16/19 at 11:41 A.M. the Administrator said they had not seen any
of the items mentioned above since starting three months ago and he/she was not aware of
all the current water-borne pathogen requirements for skilled nursing facilities.
2. Record review of Resident #309’s Face Sheet showed he/she was admitted to the facility
on [DATE] for skilled services and had the following Diagnoses: [REDACTED]. Subcutaneous
fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but
does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling).
-Non-pressure chronic ulcer of the back with necrosis (dead tissue) of the bone; and
-[MEDICAL CONDITION] (loss of movement of both legs and generally the lower trunk).
Record review of the resident’s Nursing Progress Note dated 4/10/19 showed the resident
refused his/her TB skin test.
Record review of the resident’s medical record on 4/15/19 showed there was no
documentation that showed a chest x-ray was completed.
During an interview on 4/16/19 at 10:09 A.M. Licensed Practical Nurse (LPN) D said:
-If a resident refused a TB skin test, the nurse was responsible for documenting the
refusal in the residents’ medical record.
-The nurse should contact the residents’ physician and notify the Director of Nursing
(DON).
-The nurse should obtain physician’s orders [REDACTED].
-A chest x-ray was not completed for the resident.
During an interview on 4/18/19 at 10:51 A.M., LPN A said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 59)
-When the resident was admitted , he/she refused TB skin testing.
-The resident state he/she had already had TB skin testing at the hospital.
-He/she could not locate anything in the resident’s medical record from the hospital
related to TB skin testing.
-He/she did not order a chest x-ray after the resident refused TB skin testing; and
-He/she had notified the resident’s physician and told the DON.
During an interview on 4/19/19 at 10:57 A.M., the DON and Corporate Nurse B said:
-DON: He/she expected the nurse to document the refusal for the TB skin testing in the
resident’s medical record.
-Corporate Nurse C: He/she expected the nurse to call the resident’s physician if the
resident refused the TB skin test.
–The nurse should have completed a signs and symptom screening for indicators of TB; and
–The nurse should call the resident’s physician and obtained orders for a chest x-ray.
3. Record review of Resident #40’s Admission Record showed he/she was admitted on [DATE]
and readmitted on [DATE] with tracheotomy (trach).
Record review of the Resident’s Care Plan dated 2/3/19 showed he/she has an alteration in
respiratory system due to a trach.
Observation on 4/16/19 at 12:23 P.M., [MEDICAL CONDITION] showed LPN C:
-Wash his/her hands, put on non-sterile gloves and set up supplies on a clean barrier.
-Removed gloves, washed his/her hands and donned sterile gloves.
–Opened non-sterile bottle of normal saline
–Picked up suction tubing attached to the suction machine.
–Attached the sterile suction tubing to the non-sterile suction tubing.
–Turned the suction machine on.
-Proceeded to suction the resident'[MEDICAL CONDITION] remove accumulated mucus
secretions.
-Turned off the suction machine.
-Removed the sterile tubing from the non-sterile suction tubing and
-Removed the sterile gloves and washed his/her hands.
During an interview on 4/18/19 at 10:22 A.M., LPN F said:
-Hands should be washed/sanitized:
–Before putting on gloves.
–Between glove changes.
–After removing gloves and
-When wearing sterile gloves only touch items in the sterile field or that are sterile.
4. Record review of Resident #93’s Admission Record showed he/she was admitted on [DATE]
and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Trach status.
Record review of the resident’s Care Plan dated last reviewed 3/21/19 showed:
-He/she has [MEDICAL CONDITION] to a gunshot wound, head injury.
-[MEDICAL CONDITION] needed for airway clearance and secretions.
-Oxygen [MEDICAL CONDITION] at 1.2 Litters.
-Keep [MEDICAL CONDITION] bedside and
-Stoma care as needed and per policy.
During an observation on 4/16/19 at 10:37 A.M., [MEDICAL CONDITION] showed LPN A:
-Washed his/her hands set up a sterile field and opened packages.
-Put on sterile gloves.
-Removed [MEDICAL CONDITION] cannula.
-Placed a new inner cannula.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 60)
-Changed gloves.
-Did not wash/sanitize his/her hands.
-Put on sterile gloves.
-Untied [MEDICAL CONDITION] of the collar band.
-Changed gloves.
-Did not wash/sanitize his/her hands.
-Put on sterile gloves.
-Cleaned around the outside of [MEDICAL CONDITION].
-Removed his/her right hand sterile glove.
-Put a sterile glove on his/her right hand.
-Did not wash/sanitize his/her hands.
-Cleaned under [MEDICAL CONDITION].
-Removed gloves.
-Did not wash/sanitize his/her hands.
-Put on non-sterile gloves.
-Placed the split gauze dressing under [MEDICAL CONDITION] and
-Removed gloves and washed his/her hands.
During an interview on 4/18/19 at 10:07 A.M., LPN A said he/she:
-Washes hands when entering a resident’s room.
-Uses hand sanitizer for three to four glove changes.
-Uses soap and water for the next glove change.
-Uses soap and water when through with resident cares and
-Realized that he/she did not wash/sanitize his/her hands between glove changes during
[MEDICAL CONDITION] observation by the surveyor.
During an interview on 4/19/19 at 10:55 A.M., the DON said:
-Staff should wash/sanitize his/her hands before resident cares, between glove changes and
after resident cares.
-The same hand washing/sanitizing should be done when using sterile gloves and
-Staff should not be touching non-sterile items when wearing sterile gloves.
5. Record review of Resident #610’s Face Sheet showed he/she had been admitted on [DATE]
with the following Diagnoses: [REDACTED].
-Vertebral fracture (bones in the spine crumble).
-Diabetes (a group of diseases that result in too much sugar in the blood).
-It did not show the resident had [MEDICAL CONDITION]
-The resident had a guardian.
Record review of the Baseline Care Plan dated 4/09/19 showed:
-The resident was to have oxygen.
-The resident was to have his/[MEDICAL CONDITION] and
-The resident had not been in the facility long enough to have a care plan done.
The resident had not been in the facility long enough to have an MDS done.
Record review of the (MONTH) 19, 2019 to (MONTH) 18, 2019 Physician order [REDACTED].
-The nurse was to check the oxygen saturation every 12 hours and as needed.
-The resident was to have [MEDICATION NAME] (a respiratory treatment which would include
oxygen) 3.0/0.5 every eight hours and
-There was no order for oxygen.
Observation on 4/11/19 at 10:09 A.M. showed:
-The resident had his/[MEDICAL CONDITION] on.
-The mask was dirty, the right side had a moderate amount (quarter size) of white phlegm
in it.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 61)
-The oxygen tubing from the humidifier was laying in a pool of clear liquid uncapped on
the bedside stand and
-The resident was non verbal.
During an interview on 4/11/19 at 2:30 P.M. LPN A said:
-He/she has [MEDICAL CONDITION].
-He/she tries to get into the resident’s room to check on him/her every two hours.
-He/she has been busy this shift.
-[MEDICAL CONDITION] should be cleaned or changed if dirty.
-[MEDICAL CONDITION] be suctioned if there is a lot of phlegm and
-The oxygen tubing should be changed if it was dirty.
During an interview on 4/18/19 at 12:30 P.M. the DON said if the oxygen tubing was dirty
it should have been changed.

F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement a program that monitors antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish a facility-wide
infection prevention and control program that included an antibiotic stewardship program
that included antibiotic use protocols and a system to monitor antibiotic usage. The
facility census was 113 residents.
Record review of the facility’s Infection Control Program Policy last updated 2-2018
showed:
-The facility has established and maintains an Infection Control Program.
-The facility conducts ongoing surveillance of Health Care Associated Infections and
significant infections that may require transmission-based precautions and other
preventative interventions.
-The facility investigates, controls and prevents facility infections.
-The facility maintains a record of incident and corrective actions related to infections.
-The facility conducts and trends ongoing surveillance.
-Residents with noted signs and symptoms of infection will also have a Resident infection
Control Report, completed based on the McGeer’s Criteria (long term care surveillance
definitions for infections).
-Nursing will notify the physician of all pertinent details about the resident condition,
obtain orders for diagnostic tests if applicable and for treatment.
-Antibiotic use, continued use or change in medication, will be based on the facility
practice of antibiotic stewardship, clinical symptoms, physician review, pertinent
diagnostic testing, if applicable and resident allergies [REDACTED].>-The facility has
a nurse, with designated responsibilities, as the Infection Control Nurse, who serves as
the coordinator of the Infection Prevention and Control Program.
-The Infection Control Nurse focuses on collecting, analyzing, and providing infection
data and trends and antibiotic stewardship practices.
1. Record review of the facility’s Infection Control Tracking book was not complete and
the Resident Infection Control Sheets for the last 12 months showed:
-The sheets were not filled out completely or appropriately.
–Only the antibiotic that the Physician ordered and the duration of use.
–There was no [DIAGNOSES REDACTED].
-The surveyor could not determine if there were any particular infections or issues on any

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 62)
hall or area in the facility and
-An Antibiotic report was printed for the facility for the month of (MONTH) 2019.
During an interview on 4/19/19 at 9:53 A.M., the Director of Nursing (DON) said:
-He/she took the DON position in (MONTH) 2019 and had been reviewing the Infection Control
Book.
-The facility did not have an infection control nurse and that the wound nurse was doing
the infection control.
-He/she felt that the wound nurse was not taught how to do the infection control tracking
and recording properly.
-The wound nurse was checking with the pharmacy for resident’s antibiotics and the
duration of use and listing them on the Resident Infection Control Report.
-The Assistant Director of Nursing (ADON) took over the infection control position in
(MONTH) 2019.
-The ADON was not doing the infection control track book properly in (MONTH) or (MONTH)
2019.
-The ADON was going to go through the Infection Control Certification program.
-The ADON quit on (MONTH) 11, 2019.
-He/she is in the process of completing the Infection Control Certification Program and
-He/she will update the records as much as possible after completing the program and
understanding what is supposed to be done.

F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures for flu and pneumonia vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to offer or document that the
pneumonia (lung inflammation caused by infection) vaccination was offered for three
sampled residents (Residents #54, #40, and #102) and to offer or document that the
influenza (a highly contagious [MEDICAL CONDITION] infection of the respiratory passages
causing fever, severe aching and excessive build-up of mucus in the nose or throat)
vaccination was offered to two sampled residents (Residents #40 and #102) out of 23
sampled residents. The facility census was 113 residents.
Record review of the facility’s Infection Control Program Policy last updated 2-18 showed:
-On admission, all new residents and readmitted residents will be identified for a recent
or risk of infection based on clinical signs and symptoms and documented in the medical
record and
-Newly admitted residents (guardians) will provide an immunization history for Influenza
and Pneumonia and any needed immunizations (provided consent is given) will be provided by
the facility.
Record review of the facility’s Prevention and Control of Seasonal Influenza last updated
(MONTH) (YEAR) showed:
-This facility follows current guidelines and recommendations for the prevention and
control of seasonal influenza.
-The Infection Preventionist will educate, promote and administer seasonal influenza
vaccine.
-Employees, Consultants, Health Care Providers, Volunteers and any other individuals that
are associated with the facility and have contact with the resident population will
receive

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 63)
education regarding the flu vaccination annually in accordance with the Center for Disease
Control (CDC) and State Guidelines.
-Flu Vaccination will be available to all employees during the entire influenza season.
Unless contraindicated.
-All residents and staff will be offered the vaccine.
-Residents who decline the influenza vaccine will have the reasons documented.
–The resident’s physician will be notified of their reasons for declining the vaccine.
-Residents without decision making capacity and who have no significant other or health
proxy will be immunized with the influenza vaccine annually as ordered by the Primary Care
Physician unless medically contraindicated.
-The infection Preventionist/Designee will keep data regarding the vaccination status.
-Medical Exemption is defined as a written statement by a licensed physician, physician
assistant or nurse practitioner, documenting a patient’s contraindication or precaution to
the receipt of influenza vaccination.
-Acceptable contraindications and precautions to receipt of influenza vaccination include:
–Severe allergic reaction to a previous dose or to a vaccine component.
–History of Guillian-Barre’ Syndrome (an acute form of polyneuritis (any disorder that
affects the peripheral nerves collectively), often preceded by a respiratory infection,
causing weakness and often paralysis of the limbs) within six weeks after a previous
vaccination and
–Current moderate or severe acute illness with or without fever (until symptoms have
abated).
Record review of the facility’s Pneumococcal Vaccine for Residents dated 10-16 showed:
-This center will offer pneumococcal vaccination to all admitted residents [AGE] years of
age and older unless:
–Such resident has already received the vaccination.
–Is not in need of a booster.
–Or is a person for whom it is medically contraindicated.
-Every admission/readmission, resident will be evaluated by a licensed nurse for
eligibility to receive a Pneumococcal Vaccine.
-Physician orders [REDACTED].
-Residents/representatives will be explained the risk/benefits of the vaccines and have
the right to refuse vaccination.
–If refused, appropriate entries will be documented in each resident’s medical record
indicating the date of the refusal of the pneumococcal vaccination.
-The resident/family member will sign a consent to give the pneumococcal vaccine and
-For residents who receive the vaccine, the date of vaccination, lot number, expiration
date, person administering, and the site of vaccination will be documented in the
resident’s chart.
1. Record review of Resident #54’s assessments and tracking forms showed:
-The resident entered the facility on 11/7/18.
-The resident’s admission Minimum Data Set (MDS-a federally mandated assessment tool
completed by facility staff for care planning) dated 11/13/18 showed the staff assessed
the resident as cognitively intact and the resident’s pneumonia vaccination was up to
date.
-The resident was discharged with return anticipated on 12/19/18.
-The resident re-entered the facility on 12/22/18 and
-The resident’s quarterly MDS dated [DATE] showed the staff assessed the resident as
cognitively intact and the resident’s pneumonia vaccination was up to date.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265830

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

KANSAS CITY CENTER FOR REHABILITATION AND HEALTHCA

STREET ADDRESS, CITY, STATE, ZIP

12942 WORNALL ROAD
KANSAS CITY, MO 64145

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 64)
Record review of the resident’s medical record showed no documentation of the resident
receiving or declining the pneumonia vaccine.
Record review of the resident’s vaccination tab showed the pneumonia vaccination was left
blank.
2. Record review of Resident #40’s Admission record showed he/she admitted on [DATE] and
readmitted on [DATE].
Record review of the Resident’s medical record showed no documentation of the resident:
-Receiving the influenza or pneumonia immunizations.
-Consenting to receive or declining to receive the immunizations and
-Receiving education on the risks verses the benefits if refusing immunizations.
3. Record review of Resident #102’s Admission record showed he/she admitted on [DATE].
Record review of the resident’s medical record showed no documentation of the resident:
-Receiving the influenza or pneumonia immunizations.
-Consenting to receive or declining to receive the immunizations and
-Receiving education on the risks verses the benefits if refusing immunizations.
During an interview on 4/19/19 at 9:08 A.M., the Regional Corporate Nurse Registered Nurse
(RN) B said:
-He/she was unable to find the documentation of Residents #40, #54, and #102 receiving or
declining to receive immunizations.
-A resident’s consent or declining consent for immunizations should be obtained on
admission.
-Education should be given to the resident on risks verses the benefits of receiving
immunizations if the resident refuses.
-Documentation of receiving, refusal and education should be charted in the resident’s
medical record and
-The admitting nurse is responsible for ensuring that the pneumonia and influenza
immunizations are offered and/or administered to the resident on admission.
During an interview on 4/19/19 at 10:55 A.M., the Director of Nursing (DON) said:
-The admitting nurse offers pneumonia and influenza immunizations on admission.
-The admitting nurse gets the resident’s consent or refusal form for the immunizations
signed by resident or resident representative.
-If the immunizations are refused the admitting nurse should educate the
resident/representative on the risks verses benefits of the immunizations and
-The influenza immunization should be offered annually.